Health Care in Rural America

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Health Care in Rural America

September 1990

OTA-H-434

NTIS order #PB91-104927



Recommended Citation:

U.S. Congress, Office of Technology Assessment, Health Care in Rural America,OTA-H-434 (Washington, DC: U.S. Government Printing OffIce, September 1990).

For sale by the Superintendent of DocumentsU.S. Government Printing Office, Washington, DC 20402-9325

(order form can be found in the back of this report)



Foreword

Federal policies to advance the Nation’s health have often included provisions to mitigatethe special problems in delivering health care in rural areas. Recently, however, these policieshave received renewed scrutiny in the face of reported increases in rural hospital closures,ongoing problems in recruiting and retaining health personnel, and difficulty in providingmedical technologies commonly available in urban areas. Mounting concerns related to ruralresidents’ access to health care prompted the Senate Rural Health Caucus to request that OTAconduct an assessment of these and related issues. This report, Health Care in Rural America,is the final product of that assessment. (Two other OTA papers, Rural Emergency Medical

Services and Defining “Rural” Areas: Impact on Health Care Policy and Research, havepreviously been published in connection with this assessment.)

An advisory panel, chaired by Dr. James Bernstein of the North Carolina Office of RuralHealth and Resource Development, provided guidance and assistance during the assessment.Also, three public meetings were held (in Scottsdale, Arizona; Bismarck, North Dakota; andMeridian, Mississippi) to provide OTA with the opportunity to discuss specific rural healthtopics with local and regional health practitioners, administrators, and officials. Site visits tolocal facilities were conducted in association with these activities. A number of individualsfrom both government and the private sector provided information and reviewed drafts of thereport.

OTA gratefully acknowledges the contribution of each of these individuals. As with allOTA reports, the content of the assessment is the sole responsibility of OTA and does notnecessarily constitute the consensus or endorsement of the advisory panel or the TechnologyAssessment Board. Key staff responsible for the assessment were Elaine Power, LawrenceMiike, Maria Hewitt, Tim Henderson, Leah Wolfe, Marc Zimmerman, and Rita Hughes.

u Director



Rural Health Care Advisory Panel

James Bernstein, Chairman

Director, Office of Rural Health and Resource DevelopmentNorth Carolina Department of Human Resources

Robert BerglandExecutive Vice President and General ManagerNational Rural Electric Cooperative AssociationWashington, D.C.

James ColemanExecutive DirectorWest Alabama Health Services, Inc.

Sam CordesProfessor & HeadDepartment of Agricultural EconomicsUniversity of Wyoming

Elizabeth DichterSenior Vice President for Corporate StrategiesLutheran Health SystemsDenver, Colorado

Mary EllisDirectorIowa Department of Public Health

Kevin FickenscherAssistant Dean & Executive DirectorCenter for Medical StudiesMichigan State UniversityKalamazoo, Michigan

Roland GardnerPresidentBeaufort-Jasper (South Carolina) ComprehensiveHealth Center

Robert GrahamExecutive Vice PresidentAmerican Academy of Family PhysiciansKansas City, Missouri

Alice HershExecutive DirectorFoundation for Health Services ResearchWashington, D.C.

David KindigDirectorPrograms in Health ManagementUniversity of Wisconsin-Madison

T. Carter Melton, Jr.PresidentRockingham Memorial HospitalHarrisonburg, Virginia

Jeffrey MerrillVice PresidentRobert Wood Johnson FoundationPrinceton, New Jersey

Myrna PickardDeanSchool of NursingUniversity of Texas—Arlington

Carolyn RobertsPresidentCopley Health Systems, Inc.Morrisville, Vermont

Roger RosenblattProfessor & Vice ChairmanDepartment of Family MedicineUniversity of Washington

Peter SybinskyDeputy Director for Planning, Legislation, and

OperationsHawaii Department of Health

Fred T“inningPresidentKirksville College of Osteopathic MedicineKirksville, Missouri

Robert VraciuVice PresidentMarketing & PlanningHealth Trust, Inc.

Nashville, Tennessee

Robert WalkerChairmanDepartment of Family and Community HealthMarshall University School of MedicineHuntington, West Virginia

NOTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques p rovided by th e advisory panel memb ers.

Th e panel does not, however, necessarily approve, disapprove, or endorse this xeport . OTA assumes full responsibility for the

report and the accuracy of its contents.

iv



OTA Project Staff—Health Care in Rural America

Roger C. Herdman, Assistant Director, OTA Health and Life Sciences Division

Clyde J. Behney, Health Program Manager

Project Staff

Elaine J. Power, Project Director l

Lawrence H. Miike, Project Director*

Tim Henderson, Analyst

Maria Hewitt, Analyst Leah Wolfe, Research Analyst

Marc Zimmerman, Analyst 3

Rita A. Hughes, Research Assistant 4

Sharon Hamilton, Research Assistant 5

Katherine Eddy Cox, Research Assistant 6

Administrative Staff

Virginia Cwalina, Office Administrator Carol A. Guntow, P.C. Specialist

Carolyn D. Martin, Word Processor Specialist

Eileen Murphy, P.C. Specialist

Contractors

Jonathan Chin, Catonsville, MD

Monty Dube, McDermott, Will, and Emery

Torn Ricketts, University of North CarolinaDavid Sheridan and Linda Kravitz, Chevy Chase, MD

Don Stamper, University of Missouri-Columbia Hospitals and ClinicsHarvey Wolfe and Larry Shuman, Monroeville, PA

National Rural Health Association

‘From Ma y 1989.Wntil May 1989.lhti.1 August 1989.4

From June 1989.f’From June 1990.6Until June 1989.



Contents

Page

Part I: SummaryChapter 1. Summary and Options . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... .......””””””””” 5

Part II: An Overview of Rural Populations and Health ProgramsChapter 2. Rural Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ...........”.””””””””””””” -“” 35Chapter 3. Federal Programs Affecting Rural Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Chapter 4. The State Role in Rural Health . . . . . . . . . . . . . . . . . . . . . . . .. .. .. .. .. ... ... .....+. 87Part III: Availability of Rural Health ServicesChapter 5. Problems and Trends in Rural Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Chapter 6. Short- and Long-Term Strategies for Effective Change by Rural Providers.. . . . . 157Chapter 7. Regulatory and Legal Concerns for Rural Health Facilities . . . . . . . . . . . . . . . . . . . . 181Chapter 8. Collaborative Opportunities Between Rural Health Facilities and Government . . . 197

Chapter 9. Conclusions: Availability of Rural Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 211Part IV: Availability of Rural Health PersonnelChapter 10. The Supply of Health Personnel in Rural Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

Chapter 11. Identifying Underserved Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287Chapter 12. Problems in the Recruitment and Retention of Rural Health Personnel . . . . . . . . . 315Chapter 13. Strategies To Recruit and Retain Rural Health Professionals . . . . . . . . . . . . . . . . . . 335Chapter 14. Conclusions: The Availability of Health Personnel in Rural Areas . . . . . . . . . . . . 371Part V: Two Examples of Specific ServicesChapter 15. Maternal and Infant Health Services in Rural Areas . . . . . . . . . . . . . . . . . . . . . . . . . . 379

Chapter 16. Rural Mental Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

Appendixes Page

Appendix A. Method of Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 437

Appendix B. Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439Appendix C. Definitions of Hospitals in OTA Analyses of 1987 American Hospital

Association Survey Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442Appendix D. Background Material for Two OTA Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443Appendix E. Rural Health Care Projects Funded by the Robert Wood Johnson Foundation and

the W.K. Kellogg Foundation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462Appendix F. Census and DHHS Regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465

Appendix G. Field Workshops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467Appendix H. Summary of OTA Special Report on Rural Emergency Medical Services . . . . . 475Appendix I. Organizational Charts: U.S. Department of Health and Human Services and

Health Resources and Services Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476Appendix J. Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517



Glossary of Abbreviations

—American Academy of Family Physicians—American Academy of Nurse Practitioners

AAPA —American Academy of Physician Assistants

ACNM —American College of Nurse-MidwivesACOG —American College of Obstetricians andGynecologists

ADAMHA--Alcohol, Drug Abuse, and Mental HealthAdministration (PHS)

ADMS —Alcohol, Drug Abuse, and Mental HealthServices Block Grant

AFDC —Aid to Families with Dependent Children—American Hospital Association

AHCPR —Agency for Health Care Policy and

Research (PHS)AHEC —area health education center—allied health professional—American Medical Association

AOA —American Optometric AssociationASC —ambulatory surgery centerBHCDA —Bureau of Health Care Delivery and

Assistance (HRSA, PHS)BHPr —Bureau of Health Professions (HRSA, PHS)BLS —Bureau of Labor Statistics (Department of

Labor)CCEC -Community Clinic/Emergency CenterCDC —Centers for Disease Control (PHS)

-Code of Federal RegulationsCHC -community health centerCHMSA —Critical Health Manpower Shortage AreaCLT -clinical laboratory technician/technologistCMHC -community mental health centerC/MHC Community/migrant health centerCNM -certified nurse-midwife

COBRA -Consolidated Omnibus BudgetReconciliation Act of 1985

COGME —Council on Graduate Medical EducationCONCRNACTDEFRADHEW

DHHSDODRGsEACHECHEMTEPSDT

ESWLFMG

FmHAFPFRFTC FTCA

-certificate of need-certified registered nurse anesthetist-computed tomography—Deficit Reduction Act of 1984—Department of Health, Education, and

Welfare (now DHHS)—Department of Health and Human Services-doctor of osteopathy-diagnosis-related groups—Essential Access Community Hospital—Emergency Care Hospital-emergency medical technician—Early and Periodic Screening, Diagnosis,

and Treatment (Medicaid)--extracorporeal shock wave lithotripsy—foreign medical graduate

—Farmers Home Administration (USDA)—family nurse practitioner—family practitioner—Federal Register—Federal Trade Commission—Federal Tort Claims Act

—full-time equivalentFY —Federal fiscal yearGAO -General Accounting Office (U.S. Congress)G/FP —general/family practitionerGME —graduate medical educationGMENAC--Graduate Medical Education National

Advisory CommitteeGP —general practitionerGPCI -Geographic Practice Cost IndexHCFA —Health Care Financing Administration (DHH.S)HHI —Herfindahl-Hirschman Index

HMO —health maintenance organizationHMSA —Health Manpower Shortage Area

HPOL —HMSA Placement Opportunity ListHRSA —Health Resources and ServicesAdministration (PHS)

—U.S. Department of Housing and UrbanDevelopment

—Index of Medical UnderserviceIOM —Institute of Medicine

IRS —Internal Revenue ServiceJCAHO —Joint Commission on the Accreditation of

Healthcare organizations

LHD —local health departmentLP/VN —licensed practical/vocational nurse

—Medical Assistance Facility—medical doctor

MHC —migrant health centerMHREF —Montana Hospital Research and Education

Foundation MHS —multihospital systemMLP —midlevel practitionerMPCA —Michigan Primary Care Association

—magnetic resonance imagingMSA —metropolitan statistical areaMUA —Medically Underserved AreaMUA/P —Medically Underserved Area/PopulationMUP —Medically Underserved PopulationNGA —National Governors’ Association NHSC —National Health Service Corps (BHCDA,

HRSA, PHS)—National Institute of Mental Health

(ADAMHA, PHS)NLM —National Library of MedicineNP —nurse practitioner

—National Rural Health AssociationOB/GYN -obstetrician/gynecologistOBRA -omnibus Budget Reconciliation ActOMB —U.S. Office of Management and BudgetORH -office of rural health (State-level)ORHP -Office of Rural Health Policy (HRSA, PHS)OT -occupational therapist

OTA -Office of Technology Assessment (U.S.Congress)PA —physician assistantPCCA —primary care cooperative agreementPHHS —Preventive Health and Health Services Block

Grantvii



PHS —Public Health Service (DHHS)PPA —private practice assignmentPPO —private practice option .PPRC —Physician Payment Review CommissionPPS —prospective payment system (Medicare)

PRO —peer review organizationProPAC —Prospective Payment Assessment Com-mission

PT —physical therapistRBRVS —resource-based relative value scale (Med-

icare)RHC —rural health clinic (Medicare/Medicaid-

certified)—registered nurse

RPCH —Rural primary Care Hospital

RRC —rural referral center (Medicare-certified)RT —respiratory therapistSCH -Sole Community Hospital (Medicare-

certified)SDMIX -South Dakota Medical Information Ex-

changeSIDS —sudden infant death syndromeSNF —skilled nursing facilitySOBRA -Sixth Omnibus Budget Reconciliation

Act of 1986SSI -Supplemental Security IncomeU.s.c. —United States CodeUSDA —United States Department of Agricul-

ture

WAMI —Washington, Alaska, Montana, and Idaho

. Vill



Part I

Summary



Chapter 1

Summary and Options



CONTENTSPage

INTRODUCTION AND SCOPE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PROBLEMS AND CONSIDERATIONS IN RURAL HEALTH CARE . . . . . . . . . . . . . . .

The Health and Health Care Access of Rural Residents . . . . . . . . . . . . . . . . . . . . . . . . . . . .The Availability of Rural Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The Federal Role in Rural Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

RURAL HEALTH SERVICES: ISSUES AND OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . .

Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Options for Congressional Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

RURAL HEALTH PERSONNEL: ISSUES AND OPTIONS s . . . . . . . . . . . . . . . . . . . . . . . .

Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Options for Congressional Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TWO SPECIFIC SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Issues and Options in Maternal and Infant Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Issues and Options in Mental Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55578

10

1013171720252527

Box

l-A. Federal programs

Figure

1-1, U.S. Rural and Rural

To EnhancePage

Rural Health Resources . . . . . . . . . . . . . . . . . . . . . . . . . . 9

FiguresPage

Farm Population, Selected Years, 1920-88 . . . . . . . . . . . . . . . . . . 61-2. Trends in Hospital Utilization by Metropolitan and Nometropolitan Residents,

Selected Years, 1964-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71-3. Distribution of Community Hospitals in Metropolitan and Nonmetropolitan Areas,

1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

TablesTable Page

1-1. Characteristics of Metropolitan and Nonmetropolitan Community Hospitals,1984-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1-2. Physician-to-Population Ratios (MDs only) by County Type and Population,1979 and 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1-3. Availability of Primary Care Physicians by County Type and Population, 1988 . . . . 18



Chapter 1

Summary and Options

INTRODUCTION AND SCOPE

This report is about access of people in ruralAmerica to basic health care services.

The 1980s witnessed rural economic decline andinstability, major changes in Federal health pro-grams, and increasing concern about the long-termviability of the rural health care system. Thisconcern prompted the Senate Rural Health Caucusand the Ranking Minority Member of the SenateCommittee on Labor and Human Resources torequest that OTA assess the availability of healthservices in rural communities, the problems ruralproviders face, and the remedial strategies that mightbe influenced by Federal policy.

l

This report focuses on trends in the availability of

primary and acute health care in rural areas andfactors affecting those trends.

2The rest of this

chapter summarizes OTA’s findings and conclu-sions on rural health care availability and presentsoptions for congressional consideration. Many of these options bear some similarity to proposals byothers to improve rural health care services, al-though the details may differ considerably. Theremainder of the report examines in detail the issues

faced by rural facilities providing health servicesand by physicians and other rural health personnel.To provide examples of how these issues may playout, it also discusses in more depth two specificgroups of services: maternal and infant healthservices and mental health services.

Although the affordability of health care is animportant factor in access to care by rural residents,

the fundamental issue of uninsured populations anduncompensated care is beyond the scope of thisreport, since it encompasses the urban as well as therural health care system and has broad ramifications.Moreover, even if it were possible to enable allpatients to adequately compensate providers, policy-makers would still find it necessary to consider

measures to overcome the special access problemsof underserved areas and populations. Thus, thereport does not discuss in depth either healthinsurance coverage or health care financing. Instead,it considers these factors in terms of their influenceon the availability and financial viability of providers.

Two other important issues are also beyond thescope of this report. First, the importance of ruralhealth care providers as sources of employment andincome is not addressed here, although it is a vitalissue in many rural communities. Second, this reportdoes not examine the quality of rural health care inany detail, although it is clear that the qualityimplications of rural health interventions deservescrutiny. But such an examin ation would have toproceed with care. By necessity, an evaluation of thequality of a service provided in rural areas must bemeasured against the implications of having nolocally available service at all.

PROBLEMS AND

CONSIDERATIONS IN RURALHEALTH CARE

The Health and Health Care Access

of Rural ResidentsDuring this century, the rural population has

become an increasingly smaller proportion of thetotal U.S. population (figure l-l). As of 1988, about23 percent of the U.S. population lived in nonmetro-politan (nonmetro) counties (631). About 27 percentof the U.S. population lives in ‘‘rural’ areas asdefined by the Census Bureau (places of 2,500 orfewer residents) (632), and slightly more than 15percent of the population is rural by both defini-tions.

3Throughout this report, “rural” refers to

nonmetro areas unless otherwise stated.

Rural residents are characterized by relativelylow mortality but relatively high rates of chronicdisease. After accounting for expected differences

ITw~ ~thtirepo~ ~repm~ ~ ~om=tionwith this assessmenthave ~eady beenpubfished: ~efi~~~g ‘ ‘Rural’ AreaS:Impact on HeaZth Care Policy

and Research (released July 1989), and Rural Emergency Medical Services (released November 1989).z~e repo~ does note xamine issues relating to the Indian Health Service (IHS) or health-care access for Native Americans who receive their carefrom the IHS. Previously published OTA reports examined these issues in detail (616,624).

3see the related ()~ s~ paper for a de~ed dismssion of the implications of different deftitions Of “rural” and the applications of thesedefinitions (255).

–5–



6 qHealth Care in Rural America

Figure 1-1—U.S. Rural and Rural Farm Population,Selected Years, 1920-88

250

200

150

100

50

0

Millions ..A ,“0 . . .

16 1

20 3

17 9

m

1920 1930 1940 1950 1960 1970 1980 1986 1987 1988Year

- Urban = Rural non-farm ®d Farm

aBased on the census Bureau’s definition of the rural population.bThe rural population figures from 1950 on refleet definitional changes. Had

the previous definition been used, the 1950 rural population would havebeen 60,948,000, or 40 percent of the total U.S. population.

SOURCE: Office of Technology Assessment, 1990. Data from U.S.Department of Commeree, Bureau of the Census, jointly with theU.S. Department of Agriculture, “Rural and Rural Farm Popula-tion: 1988,” Current Population Reports, Series P-20, No. 439(Washington, DC: U.S. Government Printing Office, September1989).

due to age, race, and sex distributions between urbanand rural areas, mortality rates in rural areas are 4percent lower than in urban areas (626). Two notableexceptions exist: in rural areas, infant mortality isslightly higher (10.8 v. 10.4 per 1,000 infants), andinjury-related mortality is dramatically higher (0.6 v.

0.4 per 1,000 residents). Chronic illness and disabil-ity, on the other hand, affect a greater proportion of the rural than the urban population (14 v. 12 percent)

(6.51 ).4There is little overall difference between

urban and rural residents in rates of acute illness.

Rural populations are unique in the extent of physical barriers they may encounter when obtain-ing health care. Even in relatively well-populated

rural areas, the lack of a public transportation systemand the existence of few local providers to choosefrom can make it difficult for many rural residents toreach facilities where they can receive care. And

persons living in low-density “frontier” counties—counties of six or fewer persons per square mile—can have geographic access problems of immense

proportions. In these counties, predominantly lo-cated in the West, there is insufficient population

density in many areas to adequately support localhealth services.

Photo credit: Peter Beam

Farming communities were especially hard-hit by

economic slowdowns during the early 1980s.

Economic barriers prevent many rural residents

from receiving adequate health care and oftenoutweigh strictly physical barriers. Rural residentshave lower average incomes and higher povertyrates than do urban residents, and one out of everysix rural families lived in poverty in 1987 (629).While some rural areas have prospered (e.g., areasthat have become retirement havens), areas whoseeconomies are based on farming and mining sufferedreal decreases in per capita income during the frosthalf of the 1980s (106). Still other rural areas havebeen pockets of poverty for decades. These areas of persistent poverty are heavily concentrated in theSouth, where 25 million of the Nation’s 57 millionrural residents live, and where 4 out of every 10 ruralresidents are poor, elderly, or both (633).

Rural residents are much more likely than urbanresidents to have no health insurance coverage (18.2

4~ese fiWes ~ age.adjust~ ~d ~erefore cannot be explained by a greater proportion of e l dm l y r e s i d en f i ~ ~ ~ meas .






Photo credit: Peter Beeson

Not all rural hospitals that have closed in recent years havebeen small. Memorial General Hospital, a 256-bed facility

in Elkins, West Virginia, closed in the mid-1980s.

respectively, in 1986). Federally funded communityand migrant health centers (C/MHCs) provide subsi-dized care to poor residents through nearly 800service sites in rural communities. Physician supplyhas been increasing for many years in both rural andurban areas; one out of every 440 people in theUnited States is now a physician.

7

Nonetheless, the future prospect for rural healthcare in the absence of intervention is grim. Rural

America cannot support its present complement of

hospitals, and the hospitals are going broke. By1987, rural hospitals as a group had higher expensesthan patient care revenues, and small rural hospitalshad higher expenses than revenues from all sources.Hospitals faced with continuing financial difficul-ties and no alternative forms of survival willcontinue to close, including some facilities that arethe only reasonable source of care in their communi-ties. Rather than drawing local patients back to local

care, many small community facilities will continueto lose wealthier patients to more distant urbanhospitals and clinics. Local facilities will be left tocontend with low occupancy rates and a highproportion of patients who cannot pay the full costsof their care. A lack of incentives and models fordeveloping appropriate networks of care may resultin an increasingly fragmented health service deliv-ery system.

Rural areas are finding it increasingly difficult torecruit and retain the variety of qualified healthpersonnel they need. In some isolated and ‘unattrac-

tive’ areas, an absolute lack of providers maybecome a chronic situation. The number of areasdesignated by the Federal Government as primarycare Health Manpower Shortage Areas (HMSAs)has not changed significantly since 1979. And in1988, 111 counties in the United States, with a total

population of 325,100, had no physicians at all(665). Half a million rural residents live in countieswith no physician trained to provide obstetric care;

49 million live in counties with no psychiatrist.States overwhelmingly rate health personnel short-ages as a top problem area and a top focus of Staterural health activities (627).

No single strategy is appropriate to all ruralareas or all health care providers. Rural NorthDakota is not the same as rural Mississippi. Ruralhealth problems and issues vary dramatically by

region, State, and locality. The success of strategiesto address these problems will also vary, and somestrategies that are vital to a few communities mayoffer little to others. Furthermore, even in a singleState or locality, multiple approaches are more likelythan single strategies to obtain results.

The Federal Government cannot fix all ruralhealth problems. It cannot force community consen-sus, or create new structures directly adapted to local

needs, or overcome all State-level barriers to change.But it can create an environment that facilitates theseactivities, it can furnish the information States andcommunities need to know before undertaking them,and it can be the catalyst for great improvements inthe rural health care system.

The Federal Role in Rural Health

The States are heavily dependent on the FederalGovernment for assistance in maintaining and en-hancing rural health care resources; nearly one-half (44 percent) of their resources for rural healthactivities (e.g., personnel recruitment) come fromFederal sources (627). Federal health insuranceprograms such as Medicare are a large additionalFederal investment in rural health care.



Chapter 1--Summary and Options . 9

The bulk of the Federal role in rural health iscarried out through four different types of pro-grams.

8First are health care financing programs—

most notably, Medicare and Medicaid-which paydirectly for health care services. Both programsdifferentiate in a number of ways between rural andurban providers and payment to those providers.Both programs also include special exemptions togeneral payment rules for certain rural facilities andservices (e.g., physician services provided in certainHMSAs).

Second is the health block grant, under which theFederal Government allocates funds to States tospend on any of a variety of programs in a generaltopic area. Three major block grants influence ruralhealth services: the Maternal and Child Health block grant; the Preventive Health and Health Servicesblock grant; and the Alcohol, Drug Abuse, andMental Health block grant.

Third are Federal programs for which enhancing

rural health resources is an explicit goal. Box 1-Apresents some major programs in this category.

A fourth critical Federal activity is that of coordinating, undertaking, and funding research onrural health topics. Major Federal agencies involvedin this activity are the Office of Rural Health Policy(ORHP) and the Agency for Health Care Policy andResearch.

A major challenge in designing Federal ruralhealth policies is to identify those areas whereresidents’ access to basic health care is sufficientlyendangered to justify special protective measures.Endangered areas-those with chronic shortages of health personnel, for example-require special at-tention and ongoing subsidies of providers in orderto ensure a basic level of adequate health care to arearesidents. Although the present HMSA and Medi-

cally Underserved Area (MUA) designations haveshortcomings, the basic concept of designatingareas of personnel shortage and areas of poor

health is sound. Extending this concept to encompass rural hospitals and other facilities would enable more appropriate targeting of Federal health

funds to needy rural areas.

Many rural areas are prospering and have suffi-

cient health resources, although these resources maynot always be available or provided in an efficientmanner. Others have temporary health care prob-

Box l-A—Federal Programs To Enhance

Rural Health Resources

Federal rural health resource programs include:

q

q

q

q

q

q

the National Health Service Corps, which (inaddition to having some commissioned mem-bers) provides placement services, scholar-ships, and educational loan repayment forphysicians and certain other health professionalswilling to serve in certain designated HMSAs;

programs that provide grants to schools edu-

cating and training primary care providers

(e.g., family practitioners, physician assis-tants, and nurses);the Federal Area Health Education Centers

program, which links medical centers withrural practice sites to provide educationalservices and rural clinical experiences tostudents, faculty, and practitioners in a varietyof health professions;the Community and Migrant Health Centersgrant programs, which are the Federal Gov-

ernment’s most prominent activities to promoteprimary health care facilities in rural areas;Primary Care Cooperative Agreements,

through which the Federal Government assistsStates that are assessing needs for primaryhealth care and developing plans and informa-tion to address those needs; andthe Rural Health Care Transition Grant pro-gram, established in 1988, which providesgrants to small rural hospitals for strategicplanning and service enhancement.

——.—

lems, and in still other areas health providers facefinancial crises because they are losing their mostlucrative patients to urban hospitals and physicians.

In rural areas without critical and chronic problemsof endangered access, Federal policies are moreappropriately oriented towards measures to en-

hance the capabilities of providers, encourage their adaptation to changes in the health care environ-ment, and ensure consistent and fair payment

policies. Appropriate measures may include techni-cal assistance, occasional and temporary financialassistance, targeted financial incentives, and indirectsupports.

A secondary problem for Federal rural health

policies has been how to identify areas that requirespecial protection, while accommodating the tre-mendous diversity in rural health issues and prob-

SSome other Federal Prowms ~so my play a significant role in promoting the health of rural residents (e.g., the WOmeU rnfants, an d c~~en fooddistribution program of the Department of Agriculture), but those programs are not detailed here.



10 q Health Care in Rural America

Photo credit: Gail Mooney

Eight-bed Comfrey Hospital, Minnesota’s smallest hospital, includes an operating room, outpatient clinic, and24-hour emergency room.

lems in different areas of the country. Effectivetargeting of Federal resources to rural areasrequires the involvement of the States. State involve-ment includes not only enlisting the assistance of State and local agencies in identifying critical areasbut enabling States and localities to adopt and adaptprograms tailored to their own needs. Nearly one-half of States—21 of 44 States responding to an

OTA survey-already rely on their own designationcriteria instead of (or in addition to) Federal criteriafor identifying underserved areas.

The enormous diversity across States in ruralhealth problems suggests that it is also appropriateto maintain a strong State role in designing andimplementing solutions. But State capabilities tocarry out this role successfully vary considerably.Federal coordination, technical assistance, and in-

formation are crucial to States and communitiestrying to address their rural health needs.

RURAL HEALTH SERVICES:

ISSUES AND OPTIONS

Issues

The 1980s brought major changes to the Nation’s

rural community hospitals, as medical practices,technologies, and payment systems all acted toreplace inpatient procedures with outpatient care

and as remaining inpatient care became increasinglysophisticated. Both rural and urban hospitals wit-nessed substantial declines in inpatient utilization(table l-l). Changes in rural hospitals, however,were especially dramatic. Rural hospital occupancyrates

9in 1988 were only 56 percent, compared with

over 68 percent for urban community hospitals (35).With lower inpatient admissions, rural hospitals

have become more dependent on outpatient andlong-term care revenue. By 1987, nearly one-half (46 percent) of rural hospital surgery was performedon outpatients. One-fourth of rural hospitals havelong-term care units, and in these hospitals long-term care beds make up nearly one-half of the totalbeds (625).

These major declines in inpatient utilization,

compounded by increasing amounts of uncom-pensated care, have undermined the financial healthof many rural hospitals. From 1984 to 1987, theamount of uncompensated care delivered by ruralhospitals increased by over 26 percent, to an averageof more than $500,000 per hospital by 1987 (30).Nonpatient sources of revenues—in many cases, taxsubsidies—have become increasingly important tohospitals’ financial viability. By 1987, nearly all

rural hospitals had higher costs than patient carerevenues; the smallest hospitals had costs higherthan revenues from all sources (625).

Whese occupancy rates are based on total hospita3 beds, including long-term care beds.



Chapter 1--Summary and Options q 11

Table l-l--Characteristics of Metropolitan and Nonmetropolitan Community Hospitals, 1984-88

Year Percent changeCharacteristic 1984 1985 1986 1987 1988 1984-88a

3,0582,674

25286

771,807228,871

26.66.8

67.556.0

7.16.8

189.946.7

178.939.8

58.416.1

34.534.7

3,0402,638

24885

754,953223,422

26.0

6.4

67.055.1

7.17.1

184.544.9

189.0

42.9

59.916.7

39.9

42.1

3,0122,599

24683

741,391216,921

25.66.0

67.755.3

7.27.3

183.343.8

198.5

47.0

61.217.1

43.4

2,9842,549

24683

734,073212,624

25.6

5.9

68.455.7

7.27.4

183.6

43.3

217.351.8

63.617.7

46.2

-2 .6%-5.5

-3.9-3.5

-6.4-8.6

-7.7

-21.0

-4.3-8.2

-2.77.2

-10.4

-16.1

25.533.5

10.912.8

64.4

45. 9% 49.8 89.3

a

Numbers in this table do not correspond exactly to the percentage change in every case due to rounding of

some table entries. See tables in ch. 5 for more detailed data.

SOURCE: American Hospital Association, Hospital Statistics (Chicago, IL: 1985-89 eds.).

Nearly three-fourths of rural hospitals have fewerthan 100 beds (figure 1-3). These small hospitals are

in particular difficulty; they have the fewest admis-sions, the lowest occupancy, and the highest ex-

penses per inpatient day of all rural hospitals (625).

Despite these trends, rural areas in general are stillwell-supplied with hospitals. In 1986, the ratio of community hospital beds to population was about

the same in rural as in urban areas; in 14 States,bed-to-population ratios were higher in rural areas

(382). Most rural hospitals are within a reasonable

distance of another hospital (over 80 percent arewithin 30 miles), but extreme regional differencesexist; for example, hospitals are much farther apartin the less densely populated West (589).

10Although

the mid-1980s witnessed a 5.5 percent decline in thenumber of rural hospitals (table l-l), most hospitalsthat have closed in recent years have been small

facilities with low occupancy rates (692,693). Mostcommunities in which hospitals closed appear to

l~leven Pement of Wd hospitals are located in “frontier” counties (62s).




Figure 1-3—Distribution of Community Hospitalsa in Metropolitan and Nonmetropolitan Areas, 1987

300+ beda ‘2 % )

5 0 - 9 9 beda

(34%)\ ,/

//

6-49 bedsk (38%)

-f7 200-299 beda

(5%)

~—~ 1oo-199 beda

(21%)Non metro

2,594 hospitals

1. ...:.:.

. . . . . . . . .. . . . . . . .

299 beda ~

(20%).-. . . ““”.

(16%)

Met ro3,012 hospitals

~TA’sdefinition of community hospital differs slightly from the definition used by the American Hospital Association (see app. Dforexplanation of differences.)

SOURCE: Office of Technology Assessment, 1990. Data from the American Hospital Association’s 1987 Annual Survey of Hospitals.

continue to haveand acute care.

reasonable access to emergency

In fact, one of the greatest problems rural

hospitals face is the outmigration of rural residents

to urban areas for care. Studies suggest that ruralresidents (especially young and affluent residents)have been increasingly seeking care outside theirown communities, either to obtain specialized carenot available locally or to obtain alternatives tolocally available services (102b,134,237,590).

Problems faced by publicly funded facilities that

provide primary care services are somewhat differ-ent from those faced by hospitals. From 1984 to1988 the number of rural C/MHC service sitesremained relatively constant, but patient visits torural C/MHCs rose nearly 19 percent during thisperiod (658). Most of the increase in utilizationappears to be by rural residents unable to pay the fullcosts of their care. By 1987, nearly one-half of allrural C/MHC users received discounted care. More-

over, Medicaid-reimbursed visits constitute an in-creasing proportion of revenues, while the propor-tion of revenues from private pay patients hasdecreased (658). Consequently, C/MHCs remain

heavily dependent on Federal grant funds,make up nearly one-half of total revenues.

which

Despite their heavy Federal dependence, ruralC/MHCs receive 15 percent less Federal funding perpatient served than do their urban counterparts(272). Factors such as differences in the complexityof care patients require may explain some of thedifference in funding but have not been studied indetail.

Rural health care facilities have a number of options in adjusting to recent changes in the healthcare and fiscal environment, ranging from short-term options such as staff consolidation and reduc-

tion to longer term strategies such as diversificationand participation in multifacility alliances. Butmany rural facilities have not successfully appliedthese strategies.

One major barrier to the successful implementationof strategies is simple lack of community andprovider will, particularly in cases where groupshave differing views on appropriate actions. Buteven when providers have a firm direction andcommittment, they can be stymied by a lack of information on the success of alternative possiblestrategies, and the lack of community and provider



Chapter 1--Summary and Options q13

Photo credit: 17m Henderson

Great distances in areas of sparse population can limit theavailability of even the most basic local rural health

services.

technical expertise and financial resources to under-take strategic planning and other important steps.Other especially important structural barriers caninclude:

q

q

q

q

standards and requirements for Rural Health

Clinics (RHCs) and C/MHCs, including delaysin the RHC certification process and C/MHCefficiency standards that may be difficult for

small or isolated C/MHCs to meet;regulations to prevent fraud and abuse thatmay inhibit hospitals from engaging in someactions that would encourage physicians topractice in a rural area;State licensure restrictions that prevent hospi-tals from reducing the scope of services (e.g.,converting to a facility that offers only emer-gency, subacute, and primary care); and

restrictions on public hospital activities thatprevent the 42 percent of rural hospitals that arepublicly owned from providing services notexpressly or implicitly permitted by their en-abling statutes.

Federal intervention will have limited effect onsome of these barriers. But the Federal Governmentcan avoid policies that send contradictory messagesto rural providers. For example, it maybe appropri-

ate for many rural hospitals with low occupancyrates to reorient their services to place more empha-sis on outpatient care. Any changes in Federalpayment policies for ambulatory surgical services

that assumed an unrealistically low cost of providingsuch services, however, might dissuade these hospi-

tals from making appropriate changes. Uninten-tional disincentives could be minimized by perform-ing a detailed analysis of the impact of any proposednew payment system on rural providers beforeadopting such a system.

In addition to evaluating potential new healthpolicies for their impact on rural facilities, theFederal Government could take a number of specificsteps to identify and protect essential rural health

services, and to enhance the abilities of all ruralproviders to respond appropriately to changes in thehealth care and economic environment. Options forundertaking these steps are presented below.

Options for Congressional Action

Identifying and Supporting EssentialRural Health Facilities

In some rural areas, particularly those with highpoverty or very low population density, a singlefacility may be the only provider of some of thecommunity’s vital services. At a minimum, thesevital services include basic emergency, primary,acute, and long-term care.

At present there are several programs aimed atidentifying (and supporting) facilities providing one

or more of these services, specifically the C/MHCgrant programs and Medicare’s payment exceptionsfor designated RHCs, Sole Community Hospitals(SCHs), Essential Access Community Hospitals,and Rural Primary Care Hospitals. The assumptionof each of these programs is that Federal subsidies orspecial exceptions to payment rules will enableservices to be provided to populations whose healthcare access might otherwise be severely impaired.

Existing programs, however—most notably theSCH program-imperfectly identify these facilities.Furthermore, each program has its own uniquecriteria that may not be relevant to other applica-tions. One potential direction for Federal policy is toundertake a more concerted effort to identify (option1) and protect (suboptions 1A-lC) a broad range of essential facilities.

Option 1: Develop criteria to identify healthfacilities that provide essential emergency,primary, acute, and long-term care in specifiedrural areas, and develop programs to providesupport for these facilities.




The Department of Health and Human Services(DHHS) could be directed, with assistance from the

States, to make a comprehensive effort to developcriteria that could be used to designate essentialfacilities and services, which would then be eligiblefor a variety of Federal and State protections.Criteria could distinguish among facilities for whichno reasonable alternatives exist, facilities for whichalternatives exist but are more distant or otherwiseless accessible, and all other facilities. Programsusing the facility designations thus might be applied

to either the most narrowly or the more broadlydefined group of “essential” facilities.

Designation criteria for essential facilities mightinclude:

q

q

q

q

q

distance/time to nearest comparable and near-est higher level service or facility, consideringgeographical and transportation limitations;level of medical underservice and indigence of

the area population;institution’s area market share and measures of community acceptance (e.g., utilization pat-terns);evidence of plans or actions by the facility toserve critical unmet needs of the local commu-nity; and

other relevant factors (e.g., number of Medicarebeneficiaries served).

-

From the State perspective, Federal criteria oftenseem inflexible and not adaptable to relevant localconditions. To minimize this problem, the develop-ment of designation criteria should include the input and active involvement of State governments. Stateflexibility would be further enhanced by the estab-lishment of:

. minimum criteria to aid the Federal Gov-

ernment in basic and fair allocation of fundsamong States; and

. less restrictive criteria to enable States to useand modify the designations for their ownpurposes, and to enable more flexibility in theapplication of Federal programs to variouslyidentified facilities.

Some of the difficulties of applying detailedcriteria from the perspective of the Federal Govern-ment could be avoided by requiring States toactually apply the criteria and make the designations(see option 2). The Federal role could be restrictedto technical support and assistance, reviewing and

approving designations and affirming that the desig-nated facilities were eligible for relevant Federal

programs. Facilities, once designated, could also beperiodically “recertified” in order to remove thosefacilities no longer meeting the criteria.

Option 1A: Provide direct grants and subsidies to

eligible facilities.

These could include:

Time-limited subsidies to maintain operations,

and to plan and implement strategies to changethe scope or delivery of services (e.g., 1- to3-year grants through an expanded RuralHealth Care Transition Grant Program).

Continued grant support and/or special altera-tions in public sources of reimbursement to

maintain and enhance operations for facilitiesdeemed unable to achieve self-sufficiency dueto isolation or high levels of unreimbursed care.

For example, designated hospitals could con-tinue to receive reimbursement exceptionsunder the Medicare program. Alternatively, theSCH exception could be phased out altogether,and general subsidy grants analogous to thoseprovided to C/MHCs could be made availableto all eligible hospitals, separating the subsidiesfrom the Medicare program.

Option 1B: Require the Farmers Home Admin-istration (FmHA), the Department of Housingand Urban Development (HUD), and other Fed-eral agencies to give special attention to theneeds of essential rural health facilities whenmaking available loans to institutions for capitalimprovement.

Many essential rural hospitals and clinics may

lack adequate access to capital for diversifyingservices and converting facilities to other functions.Many of these providers’ basic facilities and equip-ment also may need upgrading to maintain quality of care and conform to Federal and State regulations.Increased availability of capital through FmHAdirect and guaranteed loans and HUD loan guaranteeprograms could help to ensure the financial stabilityand presence of these facilities.

Option 1C: Protect essential facilities from Federal fraud and abuse regulations that inhibit their ability to recruit and retain physicians or to beacquired by physicians.



Chapter 1-Summary and Options q15

Close organizational association with physiciansmay be the only financially feasible strategy forlong-term survival for some rural facilities, and foressential facilities the benefits of financial stabilitymay sometimes outweigh the dangers of potentialconflicts of interest. A specified ‘safe harbor’ fromfraud and abuse regulations, or a legislative exemp-tion to these laws, could provide for the arrange-ments these facilities might make to ensure theavailability of a local physician (e.g., free onsiteoffice space). In addition, specified ‘‘safe harbor’practices could encompass the purchase of small,failing hospitals by local physicians wishing toensure the availability of this resource. Whole orpartial physician ownership of health care facilitiesmay be an especially attractive option in the case of small “alternative licensure" facilities that providemostly primary, emergency, and subacute care.

To guard against abuse of this exemption, restric-tions could specify that incentives be independent of

the number of patients the physician refers to thefacility, or that a facility wishing to acquire aphysician practice could not exclude other localphysicians from its staff. Also, facilities could beprecluded from listing recruitment and retentioncosts on their Medicare cost reports.

Option 2: Provide assistance to States to helpthem identify essential facilities, remove regu-

latory barriers applying to these facilities, andoffer State-based financial support to a moreflexible set of designated facilities.

Option 2A: Provide time-limited (I- to 3-year)grants for the development of State-designated

offices of rural health to enable States to better

support rural health efforts.

The Federal ORHP is an important part of the

Federal effort to assess rural health program needsand respond to information needs. Organizationsthat can carry out equivalent duties at the State levelare likewise important. As of February 1990, 19States had instituted (and 5 more had plans for)State-designated offices of rural health (426,627).(Locations of existing offices were almost evenlydivided between State agencies and nonprofit organ-izations.) Thirty-four States reported the existence

of legislative or executive task forces or committeesto address State rural health issues (627). ThirteenStates, however, have neither an office of ruralhealth nor a State rural health task force.

Option 2B: Provide time-limited or ongoing grantsto States to help them undertake specific activitiesrelating to essential and other

facilities.

Such grants could enable States to:

q

q

q

q

q

q

q

identify and designate essentialservices;

rural health

facilities and

monitor the financial condition of essentialfacilities and services, protect against un-desirable closure, and examine the compa-rability and acceptability of the nearest healthcare facilities;provide technical assistance to enhance leader-ship and management skills, support strategicplanning, encourage reconfiguration of serv-ices and cooperative affiliations with otherinstitutions, and recruit critical staff;help subsidize existing statewide capital fi-nancing sources and/or uncompensated carepools, making them more accessible to essen-

tial facilities;encourage special local tax initiatives and thecreation of health service districts, where ap-propriate, to maintain and expand services;study the impact of Federal and State regula-tions on essential facilities, disseminate infor-mation clarifying State and Federal regulatoryrequirements, and develop model State legisla-tive and regulatory language; and

identify areas without access even to essentialprimary and other care facilities, and providefunds to establish new facilities in these areas.

Encouraging Comprehensive andCoordinated Rural Health Care

Rural patients and providers are often bothphysically and professionally isolated. As a result

they may be unable to obtain consultation andinformation and unaware of appropriate alternativesources of care. They may receive little feedback andfew resources from regional providers.

Option 3: Award small Federal grants to projectswhose goal is the development of model ruralhealth care networks.

Short-term demonstration and development

grants could be awarded by DHHS to States ornonprofit organizations to:

. identify special basic care need areas in geo-graphically remote and persistent poverty com-




munities, identify minimum service needs, andcreate and evaluate the effectiveness of service

networks in those areas;identify regional needs and service resourcesfor comprehensive and integrated care in re-gions not designated as special basic care needareas, and create and demonstrate integratedcare networks in those regions; anddevelop regional referral networks for specificservices and population groups needing partic-ular attention, using (and expanding) the peri-

natal network model.Some aspects of this option are already in place;

for example, under Primary Care Cooperative Agree-ments, States can receive funds to help identifyneeds in underserved areas. Private organizations,however, cannot receive funds directly at present forthis purpose.

As an alternative to a new funding program, the

Rural Health Care Transition Grant program couldbe expanded. A proportion of these grant fundscould be directed specifically to funding for con-sortia of hospitals and other providers wishing todevelop model arrangements for transferring andreferring patients, and for enhancing local carethrough periodic specialty clinics and continuingeducation seminars.

Longer Term Assessment of the Future of theRural Health Care Delivery System

Innovative responses to existing barriers tochange include measures to mod@ State hospitallicensure laws to permit the operation of facilitiesthat provide less than fill-service hospital care. Twoexamples are Montana’s Medical Assistance Facili-ties and California’s proposal for basic facilitieswhose license category would depend on the extentof services they offer. The Federal Government hastaken similar steps with the enactment of theOmnibus Reconciliation Act of 1989 (Public Law101-239), which permits Medicare payment to smallrural facilities that are designated Rural PrimaryCare Hospitals (RPCHs) in a limited number of States. But the RPCH is not necessarily the only orthe best model for all rural areas, and the ability of other facility models to be eligible for Medicare andMedicaid payment remains highly uncertain.

The need for such “alternative licensure” facili-ties, the variety of proposals, and the potentialimportance of these facilities to the rural health care

system warrant a comprehensive and ongoing analysis to ease their incorporation into the system.Adapting the system to accommodate these facilitiesintroduces a myriad of questions: how to pay for theservices they provide, how to integrate them into acomprehensive and coordinated system of care, andhow to ensure that they continue to provide servicesvital to their communities. Answering these ques-tions requires the input and coordination of informa-tion from a variety of Federal and State agencies.

The recently established ORHP and the NationalAdvisory Committee on Rural Health were created,in part, to address such issues. At present, ORHP hasa very small staff and a wide range of responsibility;the Advisory Committee considers a similarly broadrange of issues and meets only four times each year.These limitations at present prevent an immediate,intense examination of the structure of the ruralhealth care system.

Option 4: Establish a short-term (18-24 month)advisory task force whose purpose is to exam-ine the future of rural health delivery systemsand to provide guidance on the implementa-tion of new service delivery structures.

Ideally, the task force, comprising both public-and private-sector experts in rural health and healthcare financing, would meet frequently and would

advise DHHS and Congress. It could be coordinatedwith the current Advisory Committee-for example,by having representatives from the Advisory Com-mittee serve as part of the short-term task force. Thetask force could be staffed by an augmented ORHPto eliminate duplication of effort.

The immediate objectives of the task force couldinclude:

1.

2.

3.

assisting DHHS in the development of criteriafor identifying essential facilities (see option1);

developing guidelines under which projectsmay demonstrate the feasibility of alternativefacility and service delivery models and (if necessary) obtain waivers from Medicare andMedicaid certification requirements;

expanding and coordinating discussion onpotential methods of payment to these facili-ties (e.g., prospective payment groups, inte-grated payment for physician and hospitalservices); and



Chapter 1-Summary and Options q17

4. providing directions for research and dem-onstration efforts supporting the development

of model service delivery networks in ruralareas (see option 6).

To ensure that the recommendations of the task force could be implemented, DHHS would need tomaintain or develop complementary expertise. Forexample, DHHS staff might need to be able to:

q

q

q

compile, analyze, and make available informationon existing efforts to develop model service

structures and networks;help States and local communities to identifyregional needs and determine standards foracceptable access to comprehensive services;andparticipate in the development of both newprojects to demonstrate innovative service andfacility categories in rural areas (e.g., subacutecare facilities) and networks involving suchproviders.

Addressing Information Needs

Option 5: Expand basic research on access tohealth care in rural areas.

Specific topics that DHHS could be encouraged ormandated to study include:

Nationwide migration patterns of rural resi-dents for health services outside their localcommunities, why they occur, and their impacton the economic viability of local healthservices (particularly obstetrics services).How travel distances and transportation limita-tions affect access to hospital care in ruralareas.The costs to rural hospitals, under differentconditions, of restructuring their organizationand services in various ways (e.g., capital,operating, and regulatory costs of downsizinghospitals to alternative delivery models).The availability, accessibility, and general op-erating characteristics of rural C/MHCs, partic-ularly those in persistent poverty and frontierregions; special problems these centers face;whether these centers are able to provide asufficient scope of care, particularly obstetrics

care; and how critical they are as a source of primary care.

Option 6: Expand funding to the Office of RuralHealth Policy to administer an extended clear-

inghouse of information on innovations andsuccesses in rural health delivery.

Many States and communities would like toinvestigate and implement improved forms of healthservice delivery but do not have, and are unable topurchase, the necessary knowledge and expertise.The Federal Government has a unique capability toact as a central point for information collection anddissemination. In addition, the Federal Government

has an interest in providing assistance relating toState and local implementation of current programsin order to enhance the effective use of Federalfunds.

ORHP’s current efforts to develop an informationclearinghouse could receive supplemental support to:

q

q

q

contract researchers to develop extensive casestudies of various rural service delivery innova-

tions;work closely with private groups fundinginnovative rural health delivery demonstrationprojects to document and disseminate informa-tion on project activities and findings; androutinely analyze information collected oninnovative strategies, identify those that appearto have the broadest benefit and transferability,and identify factors that will affect their appli-

cations in other areas.

RURAL HEALTH PERSONNEL:

ISSUES AND OPTIONS

Issues

Availability of Personnelll

Physicians —Physicians have historically beenthe cornerstone of the health care system, andphysician supply has been increasing for many yearsin both rural and urban areas (table 1-2) (673).Despite the overall increase, however, rural areashave fewer than one-half as many physicians provid-ing patient care as urban areas (91 v. 216 per 100,000residents in 1985) (table 1-2) (673). In the leastpopulated counties (those with fewer than 10,000

residents), there are only 48 physicians for every100,000 people-about one physician for every

ll~s repo~ did not examine the availability of chiropractors or podiatrists.





Table 1-2—Physician-to-Population Ratios (MDs only)by County Type and Population, 1979 and 1988

a

Table 1-3-Availability of Primary Care Physicians byCounty Type and Population, 1988

a

Percent

change,

1979 1988 1979-88

Total H)a per 100,000 residents

Metro 219.3 262.6 19.7

Nonmetro 87.2 108.5 24.4

50,000 and over 116.3 146.7 26.125,000-49,999 86.8 106.2 22.410,000-24,999 62.0 74.7 20.5

0-9,999 48.6 58.2 19.6

U.S. total 188.4 227.7 20.9

Patient care Bl)a per 100,000 residentab

Metro 174.3 215.6 23.7

Nonmetro 73.3 90.5 23.550,000 and over 97.5 122.2 25.325,000-49,999 73.3 89.9 22.610,000-24,999 52.0 61.3 17,90-9,999 40.5 47.5 17.4

U.S. total 150.7 187.2 24.3

aMD data for 1988 are as of Jan. 1. Prior to 1988,data are as of Dec. 31.

b 1987 population estimates were used to calculate1988 MD ratios. Prior to 1988, population esti-mates used were for the same year as MD data.

SOURCE: U.S. Department of Health and Human Ser-

vices, Health Resources and Services Admin-istration, Bureau of Health Professions,

Office of Data Analysis and Management,Rockville, MD, unpublished data from the

Area Resource File system provided to OTA in 1989 and 1990.

2,000 residents. Over 100 U.S. counties have nopracticing physicians at all (665).

The availability of primary care physicians inrural areas is of particular concern. Primary care

physicians make up well over one-half of allphysicians who provide patient care in rural areas(table l-3),but these areas are increasingly compet-ing with urban practices (such as those associatedwith health maintenance organizations) for primarycare physicians. Osteopathic physicians (DOs), whoconstitute about 9 percent of the total U.S. physicianpopulation, make up a large proportion of ruralprimary care physicians. In small rural counties in

some States, as many as three-fourths of thephysicians are DOs (318).

Midlevel Practitioners--Nurse practitioners (NPs),physician assistants (PAs), and certified nurse-

Primarycare physicians b

Number Proportion of per 100,000 all active

residents physicians

Metro

Nonmetro

50,000 and over25,000 to 49,999

10,000 to 24,999

5,000 to 9,9992,500 to 4,999Fewer than 2,500

U.S. total

86.8

55.3

61 .8

56.1

48.5

45.9 43,4

25 .6

79.7

38%

5748

5871

818278

40

aIncludes Jan.1, 1988 MD data and 1987 DO data.bprimary care physicians include professionally

active MDs in general/family practice, internal medicine, pediatrics,and obstetrics/gynecology;and all doctors of osteopathy in patient care.

cprofessionally active physicians include physicians

in research,administration , and teaching,and physicians in Federal service.

SOURCE: U.S. Department of Health and Human Ser-vices, Health Resources and Services Ad-

ministration, Bureau of Health Professions,

Office of Data Analysis and Management,Rockville, MD, unpublished data from the

Area Resource File System provided to O’1’A

in 1989 and 1990.

midwives (CNMs) have become important medicalcare providers in rural areas and are the only licensedproviders of primary health care in some areas withno physicians. Their small numbers are increasing,although there appears to be a very gradual trendtoward specialization and urban practice even forthese practitioners. The distribution of midlevelpractitioners varies enormously by State; theseprofessionals are most likely to be found in Stateswith midlevel practitioner schools and in States thatpermit more independent practice.

Certified registered nurse anesthetists (CRNAs)are another midlevel profession that is especiallyimportant to small rural hospitals that wish toprovide basic surgical services but cannot support orattract physician anesthetists. The national supply of CRNAs, however, appears to be in decline.

Nurses—Rural hospitals have markedly fewerregistered nurses (RNs) and lower ratios of RNs tolicenced practical/vocational nurses than do theirurban counterparts (671). The proportion of RNs




who work in rural areas has decreased in recentyears, and rural areas will probably continue to be ata disadvantage when competing for the shrinking

.national supply of nurses.12On average, nurses insmaller rural counties are considerably older thanother nurses and are less likely to have baccalaureatenursing degrees, making upgrading to midleveldegrees (e.g., NJ?) more difficult.

Dentists-As with physicians, the number of dentists and the proportion of dentists enteringspecialty practice have increased considerably over

the past two decades. However, rural areas haveconsiderably fewer dentists per capita than urbanareas, and projected future shortages of dentists arelikely to worsen the situation (673,686). Despite thelarge number of dentists in general at the presenttime, there remains a small but constant demand fordentists in areas with chronic or occasional difficultyrecruiting these practitioners.

Pharmacists—There has been no national census

of pharmacists since the 1970s, and the number of pharmacists practicing in rural areas is unknown.The national supply of pharmacists is projected toincrease (673). A handful of State studies suggestthat urban/rural differences in distribution are lesssevere for pharmacists than for many other healthprofessionals, but little is known about the existenceof local areas of shortage.

Optometrists--Optometrists may be importantproviders of vision care in rural areas withoutophthalmologists. One-third of all optometrists (andone-fifth of ophthalmologists) were practicing incommunities of 25,000 or fewer residents in 1983(42). As with pharmacists, the national supply of optometrists is increasing (673), although somelocal shortages may exist.

Allied Health Professionals—The allied health

professions include a wide variety of laboratorypersonnel, therapists, technologists, emergency per-sonnel, dental hygienists, and other professionals. Astudy by the Institute of Medicine, which examined10 different allied health professions, predictedserious impending shortages in the national supplyof physical and occupational therapists, radiologictechnologists, and medical records specialists (288).The available anecdotal evidence and small-area

studies suggest that some rural facilities are alreadysuffering critical shortages of physical and occupa-


Some rural communities have limited access to basicdental services.

tional therapists and some radiologic and laboratorypersonnel.

Barriers to Rural Practice

Barriers to the availability and willingness of health professionals to locate in rural areas interveneat two levels. First, because rural areas often havepopulations too sparse or dispersed to support manysubspecialty physicians, an inadequate supply of

primary care physicians and midlevel practitioners

is a barrier to the availability of health care servicesin rural areas even if there is an oversupply of

physicians overall. Although the supply of physi-cians has grown dramatically in the past twodecades, most of the increase has been amongnonprimary care specialists. The backbone of therural health care system, however, is primary carephysicians—those who can provide a wide array of basic health services to small communities thatcannot support a full complement of specialists.Recent Federal policies have addressed this barrier

by redesigning Medicare payment to enhance pay-ment for many primary care services. Further

12Nm~@ school ~mo~ent ac~ally ~crem~ sfi@fly ~ a~defic year 1987.88, but lo~-terrn projections are Stifl pWShIlktiC.




Photo crsdit: Peter Beeson

Satellite clinics that are staffed part-time can be avital source of primary care services in many rural

communities.

Federal options discussed below include supporting

primary care physician and midlevel educationdirectly or through changes in Medicare reimburse-ment for direct medical education.

Second, within a given group of professionals(e.g., primary care physicians), personal concerns,

perceived lower financial rewards, professional

isolation, and lack of preparation for rural practice prevent many practitioners from locating and stay-ing in rural areas. Strategies to address thesebarriers and concerns through rural-oriented trainingprograms and direct financial incentives for ruralpractice have had some success in the past. Federalmeasures to address disincentives to rural practicehave been in place for two decades, but during the

1980s their funding declined. Options for reinstatingFederal interventions include targeting funding torural-oriented health professions programs and of-fering direct incentives to health professionalsthrough scholarships, educational loan repayment,and special payment or practice provisions thatapply to health professionals in underserved ruralareas. The Federal Government could also choose toenhance other resources available to rural practition-

ers (e.g., technical assistance, continuing education,long-distance consultation resources). Combinations

of strategies, rather than any single strategy, arelikely to be the most effective in improving theavailability of health professionals in rural areas.

Options for Congressional Action

Influencing the Supply of Primary Care Physicians

Option 8: Reorient or augment existing Federalfunding for graduate medical education todirect resources to primary care specialties(family practice, general internal medicine,general pediatrics, and obstetrics/gynecology).

Option 8A: Expand Federal grant funding for

primary care undergraduate and graduate medi-cal education.

The Federal Government provides grants to fam-ily practice, general internal medicine, and generalpediatric residency programs, but these grants de-clined substantially between 1980 and 1988. Grantsfor the development, improvement, and mainte-nance of undergraduate departments of family medi-cine have also decreased in recent years. Targetedfunding for primary care education is one strategyfor overcoming some of the disincentives for spe-cialty training in primary care.

Option 8B: Weight Medicare reimbursement for direct medical education costs to give preferenceto primary care specialties.

Medicare reimbursement to hospitals for directgraduate medical education expenses does notdistinguish among specialties. By altering the pay-ment formula to give greater weight, and thusprovide greater resources, to specified primary carespecialties, it may be possible to alter the mix of physician specialists without further increasing thetotal number of physicians. A difficulty in imple-menting this option would be that of developing anadequate rationale for the specific weights to beassigned to each specialty. An advantage, comparedwith option 8A, is that it could be adopted withoutincreasing overall levels of funding.

Enhancing Training and Preparationof Rural Health Personnel

Option 9: Within Federal grant programs forprimary care medical education, target fund-ing to rural-oriented programs.

Option 9A: Target a fixed percentage of grant finds for graduate medical education specifically to programs that emphasize preparation for prac-

tice in rural and undersexed areas.




To be eligible for grants, programs could berequired to encourage rural/underserved practice byincorporating into their curricula activities such as

requiring rotations for residents in rural practicesettings and providing enhanced training in mentalhealth. Alternatively, eligibility for residency pro-gram grants could be made contingent on outcome--e.g., the demonstration that a requisite proportion of graduates were practicing in rural or underservedareas a year after graduation.

Option 9B: Target a percentage of grant funds for

undergraduate medical education specifically to programs that emphasize preparation for pri-mary care practice and for practice in rural and underserved areas.

Students entering undergraduate medical edu-cation with an interest in primary care often switchto subspecialty preferences by graduation. Under-graduate exposure to primary care practice in rural

settings has been shown to positively influence thechoice for rural primary care practice. Federal grantfunds for undergraduate medical education could betargeted to programs providing such opportunities.Funding could also be targeted to schools servingareas of greatest need (e.g., allopathic and osteo-pathic medical schools in regions of low primarycare physician supply), and funded programs couldbe targets for National Health Service Corps scholar-

ship awards.

Option 10: Expand funding to training programsfor midlevel professionals, giving preference toprograms that emphasize preparation for ruralpractice.

Midlevel professionals are vital components of the rural health care system, but they are relatively

few in number. Furthermore, the rise of HMOs andthe expansion of other urban opportunities formidlevel professionals makes it more difficult forrural areas to recruit and retain these providers.Compared with funding for physician education,funding for midlevel training programs and continu-ing education is very limited. In 1988, only 11rural-focused NP programs and 1 rural-focusedCNM program were funded. Thirty-eight PA train-

ing programs are currently supported, many of which are required to develop and use methodsdesigned to encourage graduates to work in healthpersonnel shortage areas.

Current grant programs to health professionsschools that train midlevel providers could beexpanded and directed towards those programs that

incorporate rural-oriented curricula, or that demon-strate success in placing graduates in rural andundersexed areas.

Option 11: Provide grants and traineeships torural-oriented multiple competency trainingprograms for allied health professionals.

The availability of trained allied health personnel,and particularly of personnel who can perform more

than one function, is becoming increasingly impor-tant to the survival of small rural hospitals. Thesmall grant program currently authorized to fundmultidisciplinary training programs does not explic-itly include cross-training of allied health personnel.

To enhance the effectiveness of a cross-trainingprogram, continuation of finding could be contin-gent on an outcome requirement--e.g., training

programs could be required to demonstrate that asubstantial proportion of graduates were practicingin rural areas. The availability of traineeships mightalso enhance the effectiveness of a general program,by providing students from rural and underservedareas the financial incentive and capability to enrollin such a program.

Option 12: Expand funding for rural AreaHealth Education Centers, with special em-phasis on training and continuing education of nonphysician health professionals.

The original AHEC concept was to developmultidisciplinary educational experiences. AlthoughAHECs have become increasingly involved in suchactivities in recent years, most of their resourceshave been spent on physician education. AHECs area model for encouraging State and local participa-

tion in activities addressing the geographic maldis-tribution of health professionals. The program isdesigned to create lasting networks that wouldeventually be supported entirely through State andlocal funds. To extend the usefulness of the AHECmodel and encourage more comprehensive servicedelivery systems, future AHEC startup grants couldbe directed to programs that emphasize the trainingand continuing education of midlevel providers,

mental health providers, and other nonphysicianhealth professionals. AHEC “special initiative”funds could be targeted to existing AHECs for thesame purposes. The authority for AHECs could be




expanded to enable nursing schools to receiveAHEC funds directly.

Offering Direct Incentives for Rural PracticeOption 13: Expand the National Health Service

Corps (NHSC) by increasing funding for boththe State and Federal components of the NHSCLoan Repayment Program and by reinstatinga targeted Scholarship Program.

In 1988, 29 percent of all rural residents wereliving in federally designated HMSAs (665). This

number has not changed appreciably during the past5 years, indicating a need for ensuring the availabil-ity of health professionals who have at least ashort-term commitment to serving in these areas.Federal investment in the NHSC declined dramati-cally in the 1980s and is now embodied primarily inFederal- and State-administered loan repaymentprograms. The Federal Loan Repayment Programwas funded at $3.9 million in 1989 and that year

recruited 112 professionals, mostly physicians. Atpresent, there are only seven State NHSC LoanRepayment programs.

13

The Loan Repayment program provides an incen-tive to recently graduated practitioners that isparticularly appropriate for recruiting physiciansand dentists, for three reasons. First, it does notrequire any commitments until the practitioner hasfinished his or her education, leading to lesslikelihood of default. Second, recipients are availa-ble almost immediately. Third, the level of indebted-ness among medical and dental students has in-creased dramatically in recent years, and the pool of interested applicants to an expanded loan repaymentprogram is likely to be large.

The State and Federal components of the loanrepayment program have complementary advantages.

The State program efforts are more localized thanFederal efforts, and they attract providers who arewilling to serve but want the assurance that they cancarry out their service obligation within their Stateof residence. In addition, the program requirementthat States match Federal funds encourages greaterState participation in health personnel distributionactivities.

Maintaining g the Federal program would ensurethat some obligated providers were available toserve in underserved areas in States without their

own loan programs, and it would attract providersinterested in new locations.

Available data indicate that the original NHSCScholarship Program, while expensive, was highlysuccessful at placing providers in shortage areas. Arenewed scholarship program would be especiallyappropriate for midlevel providers. Their relativelylow educational costs (compared with those forphysicians) lead to correspondingly lower educa-tional indebtedness, making loan repayment a rela-tively weaker policy tool, while making a scholar-

ship program less expensive for the Federal Govern-ment. Scholarships for other health professionsstudents could be targeted to those from low-income, minority, or rural backgrounds. Thesestudents are somewhat more likely than others topractice in undersexed areas after graduation, andthey are less likely to be able to afford the economicburden of a health profession education.

Other measures could also be taken within boththe Loan and Scholarship programs to enhance thecapabilities of obligated professionals and to in-crease the likelihood that they would remain aftertheir obligation expires. For example:

q

q

q

Preference could be given to students who haveenrolled in a program with a rural, primary-care-oriented curriculum.

Participants could be permitted to serve theirobligations at a single site regardless of anychange in the area’s designation status duringtheir period of obligation.

The NHSC could actively coordinate with otherprograms (e.g., the AHEC program) to ensuresupport for scholarship recipients during theireducation and periods of obligation. Supportmight include such features as rural preceptor-

ship, practice management training, technicalassistance, and continuing education.

A renewed NHSC would be a major investment.If this option were implemented, the program wouldwarrant accompanying oversight (e.g., by the Gen-eral Accounting Office) in its first years to ensurethat funds were appropriately and efficiently admin-istered.

Option 14: Encourage or require States to offerbonuses under Medicaid to physicians provid-




ing services in designated HMSAs, parallelingthe current policy under Medicare.

This option would extend the benefits of in-

creased access to Medicaid as well as Medicarebeneficiaries. It would also increase incentives forphysicians less likely to provide services to Medi-care beneficiaries (e.g., pediatricians, obstetrician/ gynecologists). Medicaid bonuses might be espe-cially appropriate for physicians providing obstetricservices in areas with shortages of obstetricians.

Option 15: Offer tax incentives to health provid-

ers in specified rural and underserved areas.Direct and time-limited tax incentives for primary

care providers (physicians and midlevel profession-als) serving underserved populations might over-come perceived or real financial disincentives tolocating and practicing in rural areas. Tax incentivescould be offered to providers in all rural areas, butthis policy could be expensive without improvingavailability in the areas of greatest need. If theseincentives are linked to federally designated short-age or underserved areas, however, their continua-tion should not be dependent on the continued statusof the designation (i.e., if the area is ‘redesignated’during the term of the incentive, the incentive shouldnot be removed).

Option 16: Allow a “grace period” before de-designating HMSA areas, populations, and

facilities.For HMSAs with small populations, the addition

of a single physician (or the retention of an NHSCphysician past his or her period of obligated service)can mean the loss of designated status. The suddenloss of resources dependent on continued designa-tion (e.g., Medicare physician bonus payments,placement of NHSC personnel, and qualification asa Rural Health Clinic under Medicare rules) mayproduce unintentional negative consequences.

A “grace period” could encourage existingproviders to stay while permitting the FederalGovernment to direct new available personnel tomore needy areas. For example, if the addition of aprovider in a designated HMSA raises the provider-to-population ratio above the allowable knit and theHMSA is targeted for dedesignation during periodic

review, that HMSA could be placed on a provisionallist that received close monitoring. HMSAs on thelist might receive no new resources but couldcontinue existing resources linked to designation. If

at the end of the 2-year period the ratio was stillabove the allowable limit, that HMSA could beredesignated. Such a policy could be limited to

primary care HMSAs or applied to all types of .HMSAs.

Option 17: Authorize and implement a Staterural health personnel grant.

A drawback to all rural health personnel programsoperated from the Federal level is the inability toadapt strategies to local concerns and conditions. AState with a school to train physician assistants, for

example, may most effectively address health per-sonnel shortage problems by enhancing this school’scurricula and providing scholarships to its students.In another State, absolute health personnel shortagesmight be less a problem than the provision of specific services, such as obstetrics; such a Statemight find that paying malpractice premiums forrural obstetrics providers was a more effectivestrategy than direct recruitment of more physicians

to rural areas. A broadly defined grant to Stateswould transfer responsibility to the individual Statesto decide how they choose to allocate the fundsamong health professions programs and direct in-centive programs to enhance the supply of healthprofessionals in rural areas. Such a grant could eitheraugment existing Federal programs or replace someof them.

Under a rural health personnel grant program,States could be allocated grant funds based on aformula developed by DHHS (e.g., percentage of population that is rural; number of rural residentsliving in undeserved or personnel shortage areas).Within the grant, States could spend funds on any of a list of relevant specified activities such as:

q

q

q

q

q

q

grants to State health professions schools with

rural-oriented curricula;Medicaid payment incentives for services pro-vided in underserved areas;

Medicaid bonus payments for “dispropor-tionate share” providers (those with unusuallyhigh caseloads of Medicaid and uninsuredpatients);

scholarship and loan programs;

other recruitment mechanisms (e.g., placement

services, State tax incentives);purchase of malpractice insurance premiumsfor rural obstetrics providers (obstetricians,family practitioners, CNMs, NPs);




innovative continuing education programs forrural professionals; anddevelopment of appropriate curricula and es-

tablishment of community training programs(e.g., in local hospitals and community col-leges) for rural residents interested in one of theallied health professions, and for current alliedhealth personnel wishing to extend their ac-creditation to more than one area.

The expertise among State governments regardingthe administration of rural health programs varies

considerably. Some States are capable of designingand administering a detailed array of incentive andgrant programs, while others have much morelimited capability at present. As a prerequisite toreceiving funds under such a grant, States could berequired to provide a plan outlining the activities tobe funded and indicating that the State has anadequate administrative capability (e.g., an Office of Rural Health or analogous body) to carry out the

funding activities. In addition, States could berequired to provide the Federal Government withbasic information on the programs actually fundedover the preceding year as a prerequisite for renew-ing the grant. This information would not onlyenable some oversight of expenditures but wouldprovide the basis for the Federal Government toassist in information transfer among States regard-ing innovative programs.

Removing Barriers to Midlevel Practice

Option 18: Require States to reimburse underMedicaid for the services of NPs and PAs inrural areas, as long as these services arepermitted by State practice acts.

Current Federal policy requires States to reim-burse under Medicaid for services provided bypediatric and family NPs (Public Law 101-269). Italso allows States to exercise the option of reimburs-ing for other NP and PA services, and nearlyone-half of all States now do so to some degree. TheFederal policy requiring States to provide Medicaidreimbursement for CNM services provides a prece-dent for a more general policy. As with CNMs,Federal policy could prevent State Medicaid pro-grams from requiring the direct personal supervisionof a physician during the delivery of NP and PAservices. Restricting the requirement to rural areasmight provide an additional incentive for NPs andPAs to locate in these areas, while a broader policy

might encourage their expanded use in urban as wellas rural settings.

This option carries weight only where State lawspermit midlevel practitioners to operate under off-site supervision. The Federal Government has tradi-tionally not dictated the scope of practice that Statespermit of their licensed health professionals. (Option19 addresses a potential Federal role in the reexami-nation of State licensure restrictions.)

Option 19. Encourage DHHS to sponsor a confer-ence to discuss models and guidelines for State

nurse and medical practice act revision thatwould enhance the capabilities of midlevelpractitioners to provide primary health care inrural and underserved areas.

Midlevel practitioners can provide a limitednumber of basic health services in areas not ade-quately served by physicians. Their ability to do so,however, is legally restricted in many States, partic-

ularly for PAs. A conference, sponsored by DHHS,would give representatives from different parts of the government and health care an opportunity toreevaluate the suitability of existing limits to midlevelpractice. Participants might include experts from themedical, PA, and advanced nursing professions,representatives from State and Federal agencies, andrepresentatives from other sectors of the health careindustry. Guidelines developed by such a panel

could help States evaluate and implement appropri-ate changes to their own regulations.

Improving the Information Base

Option 20: Improve monitoring of the MedicarePhysician Bonus Payment Program to find outhow well it works.

The Medicare physician bonus program wasrecently expanded to provide a 10-percent bonus forall physician services in all primary care HMSAs, inorder to increase access to services for Medicarebeneficiaries. It is not clear whether a 10-percentbonus on Medicare payment is sufficient to attractphysicians to areas where they would otherwise notchoose to locate, or whether it improves the retentionof providers already in these areas. The Medicarecaseload varies greatly from physician to physician,and the strength of the bonus incentive probablyvaries accordingly. To improve DHHS’s ability toevaluate the program, carriers could be required tosubmit to the Health Care Financing Administrationdata regarding the number of physicians receiving

Chapter 1--Summary and Options . 25



bonus payments and the distribution of services forwhich bonus payments are made.

Option 21: Establish a program, through the

Bureau of Health Professions, to provide smallgrants and technical assistance to States andprofessional associations to establish and im-plement uniform data collection proceduresamong the health professions.

Better data on the supply and distribution of health professionals would improve the FederalGovernment’s ability to monitor trends in the

availability of these personnel in rural areas. Mostprofessional associations collect data on the mem-bers of their profession, but these efforts aresometimes very limited, and the data are notcompatible. States likewise collect data on licensedhealth professionals, and they may include someprofessionals not represented in professional associ-ation databases. To enhance these efforts with aminimum amount of Federal resources, the Bureau

of Health Professions in the Health Resources andServices Administration could establish criteria foruniform data collection. The Bureau could thenprovide States and associations with technical assis-tance on survey sample selection methods or oncensus collection methods, make available startupfunds, and offer other appropriate assistance (e.g.,for hardware, software, and other resources).

TWO SPECIFIC SERVICES Issues and Options in Maternal and

Infant Care14

Fetal, infant, and maternal mortality are alldisproportionately high in rural areas (647,650).

15

These indicators of relatively poor rural maternaland infant health persist despite private and government-funded programs that have successfully reducedinfant mortality in targeted areas. Two potential

contributors to the relatively poorer health of rural

mothers and infants are the limited availability of

obstetric providers and access to specialized care

for women with difficult pregnancies and deliveries.

The availability of rural obstetric providers hasdeclined sharply in recent years, and over 500,000residents of rural counties-many of them in the

South-are without any physicians who provideobstetric care. In many rural areas, physicianstrained to provide obstetric services are not doing so.

Unwillingness is often due to concerns about inade-quate sources of backup, consultation, and referralthat are shared by rural physicians in all specialties.In addition, however, many physicians are limitingor eliminating their obstetric practices as a directconsequence of the high cost of malpractice insur-ance and fears of lawsuits. These trends are particu-larly disturbing in rural areas because alternativesources of obstetric care may be a considerable

distance away.

Where there are obstetric providers, they areusually general and family practitioners rather thanobstetricians. And although rural hospitals are muchmore likely than urban hospitals to offer obstetriccare, they are much less likely to offer specializedcare. Consequently, rural women with complicatedor high-risk pregnancies may have to travel consid-

erable distances to receive specialized care. Region-alized perinatal care, successfully promoted in thepast by Federal programs, can enhance access tospecialty services when obstetric or neonatal emer-gencies arise, but regionalized systems of care havedeteriorated over the past several years.

In some rural areas, women who are able--particularly those with higher incomes and privateinsurance coverage—are bypassing local facilities

to deliver in distant hospitals offering sophisticatedservices. One result may be to leave local physiciansand hospitals with an increasingly higher proportionof patients who cannot pay the full costs of their care.Rural physicians under these circumstances mayfind it particularly difficult to afford obstetricliability insurance, possibly prompting them toreduce their obstetric practices and further in-creasing the burden on remaining obstetric provid-

ers. ‘

Federal maternal and infant health programs (e.g.,Medicaid, the Maternal and Child Health block grant, and C/MHC funds) are especially important inrural areas, where the inability to pay for obstetricservices is a serious problem. In 1982, rural deliver-ies accounted for nearly one-half of all uncompen-sated deliveries. C/MHCs are particularly important

Idsee aISO options and personnel options generally (options 7 through 22).15~s finding holds tie titer adjusfig for race and sex. Unadjusted rural infant mortality rates are actually IOWer than urban rates, beCause of the

greater prevalence of white infants in rural areas.

20-810 0 - 90 - 2 QL3




Photo credit: 17m Henderson

Many rural community health centers attract a largecross-section of community residents and may be vital

sources of local obstetric care.

sources of prenatal care for many rural women,because they accept all Medicaid patients andprovide discounted care for low-income uninsuredpatients. But the expense of malpractice insurance

has reduced the ability of some federally supported C/MHCs to provide obstetric care (289). Ensuringsurvival of essential rural C/MHCs (and their abilityto provide obstetric services) is as important tomaternal and infant health as ensuring survival of essential rural hospitals.

Option 22: Extend liability coverage under theFederal Tort Claims Act to C/MHC staff and

contract providers engaged in obstetric care.The Federal Tort Claims Act currently insures

both commissioned officers of the NHSC and NHSCscholarship graduates who work as civilian employ-ees of the Public Health Service. Many C/MHCobstetric providers placed through the NHSC, how-ever, have no federally provided insurance coveragebecause they are paid through the center. Providinginsurance coverage might increase the willingnessof obstetric providers to join C/MHC staffs, toremain at these locations, and to continue to providea full range of obstetric services to C/MHC patients.

Option 23: Enhance the information base forFederal rural maternal and infant healthpolicy.

Option 23A: Investigate in more depth the urban and rural differences in perinatal health status indi-

cators.

Whether the excess of rural fetal deaths is real oroccurs because of differential reporting in rural andurban areas is unclear and deserves further investiga-

tion. The underlying cause of the excess mortality inlate infancy likewise deserves to be investigated.Clarification of perinatal health status in rural areaswould be useful in targeting programs. programs toimprove care for pregnant women might curb excessfetal deaths, while improved pediatric care couldpotentially reduce high mortality rates among olderinfants. Congress could direct the National Centerfor Health Statistics or the Agency for Health Care

Policy and Research to investigate these issues.

Option 23B: Develop a database that would allow

Federal policymakers to target resources to

States and to their rural areas with perinatal

health problems.

A number of programs have shown success inimproving access to prenatal care in the past.

16The

Federal Government could build on their success bytargeting resources for such programs to areas withhigh-risk populations, high perinatal mortality, anda high proportion of women seeking late or noprenatal care. Such areas could be identified in partwith information available on vital records (e.g.,birth certificates). The National Center for HealthStatistics, in the Centers for Disease Control, couldundertake this activity.

Option 24: Enhance the DHHS Office of Mater-nal and Child Health’s (MCH’s) ability toprovide useful information and technical sup-port to rural maternal and infant care efforts.

Option 24A: Enable and encourage MCH to support

additional demonstration projects in rural areas.

Funded projects could evaluate the feasibility of

innovative approaches to improving access to perinatal services in rural areas.

Demonstration projects funded through MCHcould be used, for example, to compare the relativecost and effectiveness of bringing providers intoisolated rural areas with providing transportationservices to the patients themselves. Among thecurrent MCH-funded rural projects is an evaluationof the use of an outreach consultation team of perinatal specialists to visit rural health districts

16Components of successfi Pmgms include: publicly supported obstetric providers, midlevel praCtitiOneIW Pe~~ @aWfiation sYstemsJinteragency coordinatio~ and use of outreach workers to recruit patients and provide followup and transportation.

Chapter I-Summary and Options . 27



(687). Demonstration project funding could beexpanded to include more model projects that:

employ nonphysician providers as rural out-reach workers,promote regional approaches to solve accessproblems,promote linkages of available perinatal re-sources, andincorporate home visits by nurses or para-professionals.

Projects could be required not only to evaluate the

effectiveness but the costs of these models.

Option 24B: Provide additional funds (or earmark a proportion of future funds) to better allow MCH to offer technical assistance on request to States

that are developing regionalized perinatal careservices that include rural areas.

A perinatal care network is an essential compo-nent of a functional network of comprehensive

health care services to rural residents. Resourcesfrom various Federal sources are available to helpStates develop regional and local networks andservices. Greater availability of technical assistancefrom MCH might help States and communities useboth Federal and local funds most effectively.

Issues and Options in Mental Health Care17

The prevalence of mental disorders in ruralAmericans is similar to that of their urban counter-parts. Despite the similarity in mental health prob-lems, the little information that exists suggests thatrural areas have substantially fewer mental healthresources than urban areas. Furthermore, whereresources exist, they are likely to be narrower inscope.

As with other health facilities, mental health

facilities face problems in serving populationsspread over vast distances. In addition, they arecaught between competing needs for services for thechronically mentally ill and services for acute andless serious conditions. Because recent Federal andState policies have tended to emphasize the former,the ability of many rural mental health providers tooffer services such as suicide prevention, education,crisis intervention, support groups, and individual

counseling for less severe mental health problemshas waned. Furthermore, other sources of services


Access to local mental health services is severely limitedin many rural areas.

(e.g., from nonprofit foundations) are less availableto fill the vacuum in rural than in urban areas.

Rural mental health professionals face problemssimilar to those of other rural health professionals.They have fewer training opportunities, fewer col-leagues with whom to consult and to discussprofessional issues, and more diverse demands ontheir time than do their urban counterparts. Primarycare physicians provide much of the mental healthcare in both urban and rural areas, but they receiverelatively little training in mental health diagnosisand treatment. Master’s level mental health profes-sionals, paraprofessionals, allied professionals (e.g.,the clergy), and volunteers are also vital providers of

rural health services.The severe shortage of psychiatrists and doctoral-

level psychologists in rural areas, the proportion of mental health care provided by nonpsychiatricphysicians, and the types of services likely to bemost acceptable to rural residents all suggest thatintegrating mental health and other health care is

especially important in rural areas. Social workers,psychologists, clinical psychiatric nurse specialists,

and paraprofessionals play an important role inextending rural mental health services to those in

17See also option 12.





Staffing crisis hotlines is a possible mental health role fortrained volunteers in rural areas.

need, and in linking these services with physicalhealth services. These linkages may include suchfeatures as health and mental health clinics sharinga single service site, routine consultation betweenphysicians and mental health center staff, or afull-time social worker providing counseling andeducational services in a community health clinic orphysician’s office. Recent legislation has expandedthe reimbursement available for certain “linkage”services, namely the mental health services providedby clinical social workers and psychologists incommunity health centers. Federal stimulation of linkage efforts themselves, however, has declinedsince the implementation of the mental health block grant in 1981.

Option 25: Provide grants to mental healthprofessions training programs that includerural-oriented curricula and/or train pro-fessionals most likely to locate in rural areas.

For example, the provisions of Public Law100-607, which provided special project grants toprofessional schools’ training programs for clinicalpsychologists, could be extended to include masters’

programs for social workers and clinical psychiatricnurse specialists. Or, grants under this law could betargeted or limited to projects emphasizing trainingfor rural practice.

Option 26: Require States to reimburse underMedicaid for mental health services providedby midlevel mental health professionals to the

extent that these services are permitted underState licensure law. Reimbursement could belimited to those services that were provided inHMSAs or MUAs and would be covered if provided by a physician.

In rural communities without psychiatrists ordoctoral psychologists, primary mental health care isprovided by either nonpsychiatric physicians or by

midlevel mental health professionals (master’s levelclinical psychologists, clinical social workers, andclinical psychiatric nurse specialists). Current Fed-eral policy covers reimbursement for the services of psychologists and social workers only in certifiedRHCs. Expanding the services for which midlevelmental health providers or their employers canreceive reimbursement would probably increaseaccess to these services in rural areas.

Option 27: Encourage the development of link-ages between rural health and mental healthservices and professionals.

Greater enhancement of linkages might includemeasures to encourage case management, sharebuilding space, develop referral patterns, and makebetter informed decisions about patient care. “Link-age workers’ could be expanded to include master’slevel nurse specialists. Federal initiatives of thiskind are currently underway for health and substanceabuse treatment, but a more permanent and consis-tent policy of linkages for substance abuse, mentalhealth, and other health services could be adopted.Specific Federal strategies could include:

q

q

q

q

reimbursement for linkage workers’ services(e.g., social workers’ services provided in

physicians’ offices, including consultative serv-ices provided to the physician);

funding for the salaries of clinical socialworkers and other mental health providers ingrants to federally funded C/MHCs;

funding for inservice training, internships, andshared training sites; and

requiring States to demonstrate that a portion of

Federal mental health block grant funds isbeing used to support linkage efforts in ruralareas as a prerequisite to continued block grantfunding.

Chapter 1-Summary and Options q 29



Option 28: Invest more resources in data collec-tion and analysis activity oriented at urban-rural comparisons of mental health and sub-

stance abuse epidemiology, and at the availa-bility of mental health services and personnelin rural areas.

The information available on rural mental healthepidemiology and services is extremely thin andprovides a poor basis for both monitoring mentalhealth status and implementing Federal policies.Even the most basic national data on community

mental health centers have been virtually nonexist-ent since 1981, and there are few reliable studies onmental health problems in rural areas. Congresscould direct the Alcohol, Drug Abuse, and MentalHealth Administration (ADAMHA) to place moreemphasis on these research activities (e.g., throughthe National Institute of Mental Health’s recentlycreated Office of Rural Mental Health).

Option 29: Encourage or require ADAMHA to

fund projects intended to

utilization of volunteers and

in service delivery.

demonstrate the

paraprofessionals

One way to help address mental health personnel

shortages is to include paraprofessionals and com-

munity volunteers in service delivery. However,little is known about effective ways to increase the

use of these providers, their acceptance in the

community, and the effectiveness of the services

they provide. Incentives to be tested in the demon-stration projects could include training programs for

paraprofessionals and clergy, reimbursement forprofessional activities to develop and train commu-nity workers, and educational support for commu-nity workers in the form of tuition for collegetraining.



Part II

An Overview of Rural Populations

and Health Programs



Chapter 2

Rural Populations

CONTENTSPage

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35WHO IS RURAL? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

THE RURAL POPULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Size and Geographic Distribution . . . . . . . . . . . . . . . . . . . .Demographic and Income Characteristics . . . . . . . . . . . . .

THE RURAL ECONOMIC ENVIRONMENT . . . . . . . . . . .THE HEALTH OF RURAL POPULATIONS . . . . . . . . . . .

Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ..+....Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Health Care Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TWO SPECIAL POPULATIONS: A CLOSER LOOK...The Rural Elderly . . . . . . . . . . . . . . .

Migrant and Seasonal FarmworkersSUMMARY AND CONCLUSIONS .

Figure2-1. Metropolitan Statistical Areas...

. . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . .

Figures

. . . . . . . . . . . . . . . . . . .2-2, Frontier Counties: Population Density of Six or Fewer

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 . . . . . . . . . . . . . . . ..++.,. . . . . . . . . . . . 50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

. . . . . . . ....+.,. . . . . . . . . . . . . . . . . . . . 52

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Page

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Persons Per Square Mile . . . . . . . . . . . 37

2-3. Industry of Employed Persons Over Age 16 in Metropolitan and Nonmetropolitan Areas,

1980. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

412-4. Health Insurance Status of Working Adults and Their Families, by Type of Industry, 1987.. 492-5. Regional Distribution of Urban and Rural Elderly Residents, 1980 . . . . . . . . . . . . . . . . . . . . . . . 55



TablesTable Page

2-1. United States Rural and Rural Farm Population, Selected Years, 1920-88 . . . . . . . . . . . . . . . . 382-2, Size and Percentage of Population in Nonmetropolitan and Rural Areas, by State, 1987 . . . 392-3. Characteristics of Metropolitan and Nonmetropolitan Populations . . . . . . . . . . . . . . . . . . . . . . . 402-4. Proportion of the U.S. Population Age 65 and Older, by Metropolitan/Nonmetropolitan

and Urban/Rural Status, 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412-5. Age Distribution of the U.S. Population Across Metropolitan and Nonmetropolitan Areas,

by Geographic Region, 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

2-6. Metropolitan/Nonmetropolitan Differences in Selected Health Indicators . . . . . . . . +. . . . . . . . 442-7. Acute Conditions Involving Activity Limitation and/or Medical Attention in Metropolitan

and Nonmetropolitan Populations, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452-8. Selected Chronic Conditions Among Metropolitan and Nonmetropolitan Residents . . . . . . . 452-9. Proportion of Metropolitan and Nonmetropolitan Residents Who Rated Their Health as

Fair or Poor, Selected Years, 1975 -88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472-10. Selected Preventive Behaviors and Risk Exposure of Metropolitan and Nonmetropolitan

Residents, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472-11. Immunization Status of Children Aged 1-4, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482-12. Percentage of Population With Health Insurance Coverage, by Age and Residence, 1984.. 48

2-13. Private Insurance Coverage of Metropolitan and Nonmetropolitan Residents, 1987......,.482-14. Insurance Coverage of the Population Under Age 65, by Residence and Income, 1987 . . . . . 492-15, Interval Since Last Contact With Physician (1988) and Dentis (1986) for Metropolitan

and Nonmetropolitan Residents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502-16. Percent of Metropolitan and Nonmetropolitan Residents Who Have Had a Physician Visit

Within the Past 2 Years, Selected Years, 1964-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512-17, Distribution of Physician Visits in Metropolitan and Nonmetropolitan Areas, by Specialty,

1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512-18. Hospital Utilization of Metropolitan and Nonmetropolitan Residents . . . . . . . . . . . . . . . . . . . . 522-19. Trends in Hospital Utilization by Metropolitan and Nonmetropolitan Residents,

Selected Years, 1964-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 32-20. Age Distribution of Urban and Rural Elderly Residents, 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . 542-21. Percent of Urban and Rural Persons Who Are Elderly, by Region, 1980 ............... ++ 562-22, Income Characteristics of Elderly Urban and Rural Residents (age 65 and older), 1979 . . . . 562-23. Living Characteristics of Elderly Urban and Rural Residents, 1980 . . . . . . . . . . . . . . . . . . . . . . 562-24. Percent of Metropolitan and Nonmetropolitan Elderly Limited in Activity Due to Chronic

Conditions, By Age, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572-25. Self-Assessed Health Status Among the Metropolitan and Nonmetropolitan Elderly,

1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

2-26. Rate of Restricted Activity Days Among the Metropolitan and Nonmetropolitan ElderlyDue to Acute and Chronic Conditions, by Age, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572-27. Utilization of Physician Services by Metropolitan and Nonmetropolitan Elderly Persons:

Average Annual Number of Physician Visits Per Person, 1983 and 1987 . . . . . . . . . . . . . . . . . 582-28. Utilization of Physician Services by Metropolitan and Nonmetropolitan Elderly Persons,

1964, 1982, and 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582-29. Hospital Utilization by Elderly Metropolitan and Nonmetropolitan Persons, 1987 . . . . . . . . . 582-30. Most Frequent Diagnoses Reported by 60 Federally Funded Migrant Health Centers,

1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592-31. Major Illnesses Reported by Migrant Farmworker Families, 1984 . . . . . . . +... . . . . . . . . . . . . 59

2-32. Utilization of Federally Funded Migrant Health Centers, 1984-88 . . . . . ............ +. . . . . 592-33. State Distribution of Migrant and Seasonal Farmworkers (MSFW) and Federal

Migrant Health Center (MHC) Funds, Fiscal Year 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

-Chapter 2

Rural Populations



Rural Populations

INTRODUCTION

“Rural’ evokes images of wheat fields and dairyfarms, long stretches of desert, and small Appala-chian communities. This chapter presents back-ground on the rural population: who it includes, theeconomic and demographic characteristics of ruralresidents, and some basic indicators of rural healthstatus.

The adjectives ‘‘urban’ and ‘‘rural’ encompassenormously diverse populations. Urban people maybe residents of large inner cities, suburbs, or smallercities and towns, each with its own characteristicsand cultures. Similarly, rural people may live intowns or open countryside; their nearest neighborsmay be across the street or 10 miles down a dirt road.Existing measures cannot convey the full diversity

of urban and rural populations, but they can providea starting place for examining the similarities anddifferences between these groups. An overviewcontrasting these basic characteristics is the goal of this chapter. Where possible, information summariz-ing aspects of rural diversity is also presented.

WHO IS RURAL?l

The term “rural” is intuitively associated withareas of small and sparsely settled population. Twomore specific definitions are commonly used forstatistical and health program purposes: the “ruralpopulation,’ as defined by the Bureau of the Census,and the ‘‘nonmetropolitan population, ’ those peo-ple living outside of metropolitan (metro) areas asdefined by the Office of Management and Budget.

The Census Bureau defines the rural population asthe population not categorized as urban. The urbanpopulation, in turn, is defined as those people living:

q in an urbanized area-a central city (or cities)and its contiguous closely settled territory, witha combined population of at least 50,000; and

. in places (towns, villages, etc.) outside of urbanized areas with populations of at least2,500 (633).

The nonmetropolitan (nonmetro) population con-sists of those people living outside of metropolitanstatistical areas (MSAs). An MSA is a county,

2or

group of counties, that includes either:

q a city of 50,000 or more residents, or

q an urbanized area with at least 50,000 peoplethat is itself part of a county or counties with atleast 100,000 total residents (634).

3

To be included in an MSA, a county that does notitself have a central city must have a specified levelof commuting to the central county(ies) and mustmeet certain other standards regarding metropolitancharacter, such as population density. Figure 2-1

shows the MSAs in the United States as of 1986.

About one-fourth of the U.S. population is either‘‘real” by the Census definition or lives in non-metro areas, but these two groups of people are by nomeans identical. About 14 percent of the populationliving in MSAs is designated by the Census Bureauas rural, while about 38 percent of the populationliving outside of MSAs is designated as urban (633).This occurs because, on the one hand, MSAs arecounty-based and may include large tracts of sparselypopulated land in outlying areas of the county. Onthe other hand, the Census “urban” designationincludes people in towns in otherwise sparselypopulated areas. Roughly 15 percent of the U.S.population is ‘rural’ by both definitions--i.e., livesneither in places of 2,500 or more residents nor inmetropolitan counties.

Each definition has its advantages. The Censusdesignations are more specific, because they arebased on smaller geographic units, such as censustracts and towns. Census tract boundaries vary overtime, however. In contrast, counties-the basic unitsfrom which MSA designations are made-haveboundaries that are relatively stable, a major advan-tage for collecting and reporting statistical data that

Isee tie related OTA Staff Paper for a more detailed discussion (2.5.3.% six New England States-Maine, New Hampshire,VermonL Massachusetts, Rhode Island, and Connecticut-MSAs comprise cities and towns,

rather than whole counties. Standards for these MSAS are based primanl“ y on population density and commuting patterns (634).3pop~ation is ~ene~y ~~~lated based on tie most recent de~~al cemus, ~~ou@ some intercens~ MSA designations t&O ~w.

–35–




I

Chapter 2--Rural Populations q 37



Figure 2-2—Frontier Counties: Population Density of Six or Fewer Persons Per Square Mile

Counties n ‘ther

./”

- ‘elected

SOURCE: U.S. Department of Health and Human Services. Health Resources and Services Administration, Bureau of Health Professions, Office of Data andManag&ment, Area Resource File, June 16, 1986.

are comparable over time. Data on “rural” resi-dents presented in this and later chapters are

actually data on nonmetro residents, unless adifferent definition is specified.

A problem of both definitions is that they are

dichotomous; they permit classification into onlytwo categories (urban/metro and rural/nonmetro).Neither can describe the urban/rural continuum, norcan they describe in any detail the range of variationthat exists within rural areas. Some researchers havedeveloped more extensive topologies in an attemptto overcome these disadvantages, relying on combi-nations of measures such as population size, popula-tion density, adjacency to a metro area, and urbani-

zation. None of the available topologies has so farfound general application to health care programs,although several of them are being used in researchefforts (255).

A particularly useful concept for the purpose of examining health care resources and access is that of “frontier” areas, defined as counties with popula-tion densities of six or fewer people per square mile(480). In such areas, physical access to health care isimplicitly difficult for a substantial proportion of residents. Frontier counties are concentrated in theGreat Plains and Western States and often extendover a large physical area (480) (see figure 2-2).

THE RURAL POPULATION

Size and Geographic Distribution

During America’s brief history as a nation, thecomposition of the U.S. population has changed

from one that was overwhelmingly rural to one thatis predominantly urban. According to Census esti-mates, 95 percent of the population was rural in1790; about 60 percent was rural at the turn of the


T bl 2 l U it d St t R l d R l F P l ti S l t d Y 1920 88



Table 2-l—United States Rural and Rural Farm Population, Selected Years, 1920-88

Rural population Farm population Number (in Percent of total Number (in Percent of Percent

Year thousands ) U.S. population thousands) rural population of total

1920. . . . . . . . . . . . . . . 51,553 49 31,359 60 30

1930. . . . . . . . . . . . . . . 53,820 44 30,529 57 25

1940. . . . . . . . . . . . . . . 57,246

1951)b. . . . . . . . . . . . . .

44 30,547 53 23

54,230 36 23,048 42 151960. . . . . . . . . . . . . . . 54,054 30 13,475 24 91970. . . . . . . . . . . . . . . 53,887 26 8,292 15 51980. . . . . . . . . . . . . . . 59,495 26 6,051 10 31986. . . . . . . . . . . . . . . 63,133 27 5,226 8 21987. . . . . . . . . . . . . . . 63,889 27 4,986 8 21988. . . . . . . . . . . . . . . 64,798 27 4,951 8 2

aBased on the Census-defined rural population. bThe rural population figures from 1950 on reflect definitional changes.Had the previous definition been

used, the 1950 rural population would have been 60,948,000,or 40 percent of the total U.S. population.

SOURCE: U.S. Department of Commerce, Bureau of the Census,and U.S. Department of Agriculture, “Rural andRural Farm Population:1988,” Current Population Reports, Series P-20, No. 439 (Washington, DC:U.S. Government Printing Office, September 1989).

20th century; and only 27 percent of the Nation’sestimated 241 million people lived in rural areas by

1988 (table 2-1) (632). In 1988, an estimated 23percent of the population-56,843,000 people--lived in nonmetro areas (631).

The absolute size of the rural population has notdeclined overall, but in recent years it has grownmuch more slowly than the urban population. Thenonmetro population grew at a rate of only 0.6percent per year during the 1980s (after a mild boom

in the 1970s, when the growth rate was twice ashigh) (631). In contrast, the metro population hascontinued to grow at rates of over l percent per year.

The rural farm population has undergone anabsolute and marked decline during this century(table 2-l). In 1920, an estimated 31 millionAmericans lived on farms. In 1988, in contrast, theCensus Bureau estimated the farm population to be

slightly fewer than 5 million--about 8 percent of theCensus-defined rural population, and about 2 per-cent of the total U.S. population (632).

Of the four major regions of the country,the Southhas both the highest proportion of its population(30percent) and the highest number of people (25million) living in nonmetro areas. The next mostrural region by this measure is the Midwest (29

percent), followed by the West (16 percent) and,finally, by the Northeast(12 percent) (631).

States vary tremendously in their degree of “ruralness’’ depending on the criterion used. Of theIO States whose nonmetro populations are largest inabsolute size, for example, only two (Mississippiand Kentucky) have more than 50 percent of theirpopulation residing in these areas (table 2-2)(631).Contrasts between States according to the definitionof "rural’’ are striking; less than one-half of Idaho’spopulation is rural according to the Census defini-tion, but over 80 percent of this State’s populationlives in nonmetro areas, the highest percentage in theUnited States (631).

Demographic and Income Characteristics

In general, rural residents are more likely thanurban residents to be white, native-born, and livingin a family headed by a married couple (table 2-3)

(633). They are also more likely to be children(underage 18) or elderly(age 65 or older). They areless likely to reemployed and to have completed ahigh-school education (633).

Rural residents have relatively low incomes. Theaverage median family income in rural areas in 1987was $24,397, about three-quarters of the averageurban family income of $33,131 (629).

50ne out of

eight urban families lived in poverty in 1987,

4~e Census B~eaudefimes thef~pop~ationm people living inrural areas onproperties ofatleast Iacreoflandwhere atbW$l,ooowOrthof agricultural products was sold (orwould have been sold) during the previous 12months (632).5~5mtio~ not

changedsince the 1980 cxmsus( 633).


Table 2 2 Size and Percentage of Population in Nonmetropolitan and Rural Areas by State 1987



Table 2-2-Size and Percentage of Population in Nonmetropolitan and Rural Areas, by State, 1987

Percent of Percent of totalSize of nonmetro total population population in Census- population in nonmetro areas defined rural areas

State (in thousands) (1987) (1980)

Alabama. . . . . . . . . . . . . . . . . . . . . . . . .

Alaskaa

. . . . . . . . . . . . . . . . . . . . . . . . .

Arizona. . . . . . . . . . . . . . . . . . . . . . . . . Arkansas. . . . . . . . . . . . . . . . . . . . . . . .

California. . . . . . . . . . . . . . . . . . . . . .Colorado. . . . . . . . . . . . . . . . . . . . . . . .

Connecticut. . . . . . . . . . . . . . . . . . . . .Delaware. . . . . . . . . . . . . . . . . . . . . , .,

District of Columbia. . . . . . . . . . . .Florida . . . . . . . . . . . . . . . . . . . . . . . . .

Georgia. . . . . . . . . . . . . . . . . . . . . . . . .Hawaii. . . . . . . . . . . . . . . . . . . . . . . . . .Idaho. . . . . . . . . . . . . . . . . . . . . . . . . . .Illinois. . . . . . . . . . . . . . . . . . . . . . . .

Indiana. . . . . . . . . . . . . . . . . . . . . . . . .Iowa. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kansas. . . . . . . . . . . . . . . . . . . . . . . . . .Kentucky. . . . . . . . . . . . . . . . . . . . . . . .

Louisiana. . . . . . . . . . . . . . . . . . . . . . . Maine. . . . . . . . . . . . . . . . . . . . . . . . . . .

Maryland. . . . . . . . . . . . . . . . . . . . . . . . Massachusetts. . . . . . . . . . . . . . . . . . .

Michigan. . . . . . . . . . . . . . . . . . . . . . . . Minnesota. . . . . . . . . . . . . . . . . . . . . , .

Mississippi. . . . . . . . . . . . . . . . . . . . . Missouri. . . . . . . . . . . . . . . . . . , . . . . . Montana. . . . . . . . . . . . . . . . . . . . . . . . . Nebraska. . . . . . . . . . . . . . . . . . . . . . . . Nevada. . . . . . . . . . . . . . . . . . . . . . . . . . New Hampshire. . . . . . . . . . . . . . . . . . .

New Jersey. . . . . . . . . . . . . . . . . . . . . . New Mexico. . . . . . . . . . . . . . . . . . . . . .

New York. . . . . . . . . . . . . . . . . . . . . . . . North Carolina. . . . . . . . . . . . . . . . . .

North Dakota. . . . . . . . . . . . . . . . . . . .Ohio. . . . . . . . . . . . . . . . . . . . . ., . . . . .

Oklahoma. . . . . . . . . . . . . . . . . . . . . . . .

Oregon. . . . . . . . . . . . . . . . . . . . . . . . . .

Pennsylvania. . . . . . . . . . . . . . . . . . . .Rhode Island. . . . . . . . . . . . . . . . . . . .

South Carolina. . . . . . . . . . . . . . . . . .South Dakota. . . . . . . . . . . . . . . . . . . .Tennessee. . . . . . . . . . . . . . . . . . . . . . .Texas. ., . . . . . . . . . . . . . . . . . . . . . . . .

Utah. . . . . . . . . . . . . . . . . . . . . . . . . . . . Vermont. . . . . . . . . . . . . . . . . . . . . . . . .

Virginia. . . . . . . . . . . . . . . . . . . . . . . .

Washington. . . . . . . . . . . . . . . . . . . . . .

West Virginia. . . . . . . . . . . . . . . . . . . Wisconsin. . . . . . . . . . . . . . . . . . . . . . .

Wyoming . . . . . . . . . . . . . . . . . . . . . . . . .

1,338303805

1,444

1,182603

238219

01,1102,204

252803

2,0221,7681,612

1,1692,0191,382

758

322546

1,8201,435

1,829

1,736

613842

175

462

0

774

1,6962,868

417

2,276

1,350

883

1,828

73

1,355

506

1,6033,194

384421

1,668

854

1,209

1,610

348

32.857.623.860.54.3

18.37.4

34.0

0.09.235.423.380.417.532.056.947.254.231.0

63.9

7.19.3

19.8

33.8

69.7

34.0

75.852.8

17.4

43.7

0.0

51.6

9.544.7

62.0

21.1

41.2

32.4

15.37.4

39.671.3

33.0

19.0

22.876.9

28.3

18.8

63.7

33.5

71.0

40.0

35.716.248.4

8.719.4

21.229.4

0.015.737.613.546.016.7

35.841.4

43.349.1

31.452.5

19.716.2

29.333.1

52.7

31.9

47.1

37.1

14.7

47.8

11.0

27.9

15.452.0

51.2

26.7

32.7

22.1

30.7

13.0

45.9

53.6

39.620.4

15.666.2

44.0

26.5

63.8

35.837.3

aThe nometropolitan population in Alaska is determined using census tract and borough boundaries rather than

county boundaries.

SOURCE: U.S. Bureau of the Census, Statistical Abstract of the United States: 1989, 109th ed. (Washington,DC: U.S. Government Printing Office, 1989).

40 . Health Care in Rural America

Table 2-3—Characteristics of Metropolitan and Nonmetropolitan Populations



p p p

Metro Nonmetro

General characteristics ( 1987)

Total population. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187,072,000 56,324,000Population density per sq mi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328 19

Social and demographic characteristics (1980)

Median age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.0 30.2

Percent of population under age 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.8% 29.4%Percent of population age 65 and over. . . . . . . . . . . . . . . . . . . . . . . . . . 10.7% 13.0%

Percent white. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.8% 88.2%

Percent Hispanic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.6% 3.2%

Percent nonwhite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.2% 11.8%

Percent black. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.7% 8.8%Percent American Indian. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.5% 1.3%Percent Asian/Pacific Islander. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.0% 0.6%

Percent native-born. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.4% 98.0%

Birth rate (births/1,000 population/year, 1977-1980) . . . . . . . . . . . 1.5 1.6

Percent of households headed by women. . . . . . . . . . . . . . . . . . . . . . . . . . 28.3% 23.9%Percent of children living with two parents. . . . . . . . . . . . . . . . . . . . 75.4% 80.1%

Education, employment, and income characteristics

Median years of education completed (1980). . . . . . . . . . . . . . . . . . . . . 11.6 10.9

Percent high school graduates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85.0% 83.1%

Percent with college education (4 or more years). . . . . . . . . . . . . . . 12.8% 9.2%Unemployment rate (1985). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.9% 8.4%

Median family income (1987). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $33,131 $24,397

Percent with family incomes below poverty level (1987) . . . . . . . . . 12.5% 16.9% White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.6% 13.7%Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.7% 44.1%Hispanic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.6% 35.6%

Percent of poor families with 2 or more workers (1983) . . . . . . . . . 15.4% 28.9%

SOURCES: U.S. Department of Comnerce, Bureau of the Census, Statistical Abstract of the United States: 1989109th ed. (Washington, DC: U.S. Government Printing Office, 1989); U.S. Department of Comnerce,

Bureau of the Census, 1980 Census: General Social and Economic Characteristics, vol. 1(Washington, DC: U.S. Government Printing Office, September 1981); U.S. Department of Commerce,Bureau of the Census, “Money Income and Poverty Status in the United States: 1987,” CurrentPopulation Reports, Series P-60, No. 161 (Washington, DC: U.S. Government Printing Office, August1988); D.L. Brown and K.L. Deavers, “Rural Change and the Rural Economic Policy Agenda for the1980’s,’I D.L. Brown, J.N. Reid, H. Bluestone et al. (eds.), Rural Economic Development in the1980’s: Prospects for the Future (Washington,1988).

compared with more than one out of every six ruralfamilies (table 2-3); the ratio approaches one out of

two for black families in rural areas (629). The ruralpoor are much less evenly distributed throughout theUnited States than the urban poor; over one-half (53percent) of poor rural people under age 65 1ive in thesouth (530).

The vast majority of employed people both withinand outside of metro areas are employed impersonalservices, manufacturing, and retail trade (figure

2-3).

6

The most striking employment difference, notunexpectedly, is in agriculture, which is the primary

DC: U.S. Department of Agriculture, September

occupation of over 7 percent of employed persons innonmetro areas (v. 1.5 percent of employed metro

residents) (633).

A major caveat to this picture of the ruralpopulation is that the definition of "rural’’ used canaffect even some of the most basic conclusionsregarding urban/rural differences. For example, asstated above, nonmetro areas have a relatively highproportion of elderly residents. By the CensusBureau’s definition, however, urban areas have a

higher proportion of elderly residents (633). Thisapparent discrepancy is resolved by closer examina-

~esethrecoccupationalgroups accountfor68 and 74 pereen~ respectively, ofemployedmetroandnonmetroresidents (633).

Chapter 2-Rural Populations q 41

Figure 2-3-industry of Employed Persons Over Age Table 2-4-Proportion of the U.S. Population Age 65



g y p y g16 in Metropolitan and Nonmetropolitan Areas,

1980

Services

Manufacturing

Retail trade

Agriculture

Construction

Transp/comm/utila

Public admin.

Fin/ins/real estateb

Wholesale trade

Mining

Forestry & fisheries

r)5 10 15 20 25 30Percent of employed persons

m Metro m Nonmetro

‘ I

35

aTransportation, communications, and public utilities.bFinanq insurance, and real estate.

SOURCE: Office of Technology Assessment, 1990. Data from U.S.Department of Commerce, Bureau of the Census, 1980 Cer?sus:

Genera/ Social and Economic Characteristics, vol. 1 (Washing-ton, DC: U.S. Government Printing Office, September 1981).

tion of the distribution of the elderly population,

which shows it to be concentrated in small ormedium-sized towns in both metro and nonmetroareas (table 2-4).

Within the nonmetro population, the generalitiesregarding rural residents obscure substantial re-gional differences. For example, nonmetro areas inthe West have a much higher proportion of childrenthan do metro areas (reflecting the profile for the

Nation as a whole), but Midwestern nonmetro areasactually have proportionately fewer children than dometro areas in that region (table 2-5) (447).

THE RURAL ECONOMICENVIRONMENT

The Nation’s rural areas are economically as well

as demographically diverse. The U.S. Department of Agriculture (USDA) has identified seven groups of nonmetro counties according to the principal eco-nomic activity

7or other predominating characteris-

tics:8

1. Farming-dependent counties—702 counties,concentrated in the Midwestern plains region,in which farming contributed 20 percent ormore of total income.

p p gand Older, by Metropolitan/Nonmetropolitan and

Urban/Rural a Status, 1980

U.S. population Percent age Area (in thousands) 65 and over

Metro. . . . . . . . . . . . . . . . 169,430 10.7

Nonmetro. . . . . . . . . . . . . 57,115 13.0

Urban. . . . . . . . . . . . . . . . 167,055 11.4

Rural. . . . . . . . . . . . . . . . 59,491 10.9

MetroUrban. . . . . . . . . . . . . . 145,451 10.9

Rural. . . . . . . . . . . . . . 23,979 9.0

Nonmetro

Urban. . . . . . . . . . . . . . 21,603 14.3Rural. . . . . . . . . . . . . . 35,512 12.2

a“Urban” and “ rural”as defined by the U. S. Census

Bureau.

SOURCE : U.S. Department of Corrmerce, Bureau of the

2.

3.

4.

5.

6.

7.

Census , 1980 Census: General Social andEconomic Characteristics, vol. 1 (Washing-ton, DC: U.S. Government Printing Office,September 1981) .

Manufacturing-dependent counties--678 coun-ties, concentrated in the Southeast, in whichmanufacturing contributed 30 percent or moreof total income.

Mining-dependent counties--200 counties, con-centrated in the West and in Appalachia, inwhich mining contributed 20 percent or moreto total income.

Specialized government counties—315 coun-

ties, scattered throughout the country, in whichgovernment activities contributed 25 percentor more of total income.

Persistent poverty counties—242 counties,concentrated in the South, in which the percapita family income in the county was in thelowest quintile in specified years between1950 and 1979.Federal lands counties—247 counties, con-

centrated in the West, in which Federal landwas 33 percent or more of the land area.

Destination retirement counties—515 coun-

ties, concentrated in the South, Southwest, andnorthern Lake States, in which the net immi-gration rates of people aged 60 and over duringthe 1970s were 15 percent or more of theexpected population in this age group in 1980(82).

?I.e., the industry tbat contributed the most to labor and proprietor income in those counties in the 1970s.8~ ~, s’70 ~omties ~d not meet tie rq~rnen~ for an y of tie 7 COU@ gKWpS and are mcla.ssifled by hS typoIo~.


Table 2-5—Age Distribution of the U.S. Population Across Metropolitan and Nonmetropolitan Areas,



by Geographic Region, 1980

Geographic region Population Under 17 17-44 45-64 65 years

and residence (in thousands) years years years and over

United States Metro. . . . . . . . . . . . . . . . . . . 150,836 25.8% 43.9% 19.9% 10.4%

Nonmetro. . . . . . . . . . . . . . . . 70,650 27.5 40.7 19.6 12.3

Northeast Metro. . . . . . . . . . . . . . . . . . . 38,861 24.9 42.0 21.3 11.7

Nonmetro. . . . . . . . . . . . . . . . 10,067 26.7 41.2 19.3 12.8

Midwest Metro. . . . . . . . . . . . . . . . . . . 38,919 26.9 43.9 19.6 9.6

Nonmetro. . . . . . . . . . . . . . . . 19,574 26.2 41.5 19.4 12.9

South Metro. . . . . . . . . . . . . . . . . . . 41,036 26.3 44.2 19.5 10.0

Nonmetro. . . . . . . . . . . . . . . . 31,467 27.8 40.0 19.9 12.3

West Metro. . . . . . . . . . . . . . . . . . . 32,021 25.1 45.6 19.0 10.3

Nonmetro. . . . . . . . . . . . . . . . 9,542 29.8 40.9 18.8 10.6

SOURCE: C.H. Norton and M.A. McManus, “Background Tables on Demographic Characteristics, Health Status andHealth Services Utilization,

m

Health Services Research 23(6):725-756, February 1989.

Rural America has undergone a major economicrestructuring over the past half century. In 1940,industries based on natural resources--agriculture,forestry, fishing, and mining--employed 40 percentof the rural labor force (93). By 1980, theseindustries accounted for fewer than 10 percent of

jobs, while service, manufacturing, and constructionindustries had become as dominants they were inurban areas (93).

The changes in the rural economy have not beenconsistently accompanied by prosperity. Rural areasin the 1970s experienced both population growthand economic prosperity. The disparity betweenrural and urban incomes narrowed during the earlypart of the decade, with rural per capita incomereaching a high of 78 percent of urban income in1973 (253). During the 1980s, however, the rural

economy slowed dramatically. The rural unemploy-merit rate skyrocketed from 5.7 percent in 1979 to10.1 in 1982, and by 1985 it was still considerablyhigher than the urban rate(8.4 v. 6.9 percent). Whenthe unemployment rate is adjusted to account fordiscouraged workers (those no longer looking for

jobs) and involuntary part-time workers, differenceswere even more extreme (13.0 percent for ruralworkers v. 9.9 percent for urban workers in 1985)

(106). The rural poverty rate increased by nearlyone-third between 1973 and 1983 (106); despiteimprovements, it was still 35 percent higher than theurban poverty rate in 1987(629).

Individual rural communities are highly vulnera-ble to economic shifts, because they are so oftendependent on a single major industry (e.g., agricul-ture). The slow employment growth in rural areasalso means that workers who lose their jobs oftencannot find alternative employment. Regional cluster-ing of particular industries and other characteristicsof rural employment also amplify the effects of someeconomic changes. Rural manufacturing employment,

for example, is heavily concentrated in blue-collaroccupations in low-wage industries. Thus, rapid joblosses in the manufacturing sector are likely to havea disproportionately negative effect on rural areas(106). In addition, rural manufacturing is heavilyconcentrated in the South, in large regions that maythus experience simultaneous employment prob-lems. The agricultural sector experienced this situa-tion in the early 1980s, leading to the “farm crisis”

that devastated much of the Midwest.

Not all rural areas fared badly during the pastdecade. Rural areas with retirement- and government-based economies experienced economic growth ashigh as that in urban areas, at least during the earlypart of the 1980s (253). But counties dependent onf arming, mining, and manufacturing suffered veryslow economic growth. In farming and mining areas,

real per capita income (adjusted for inflation)actually decreased between 1979 and 1984 (253).The economic upswing of the early 1980s for themost part left rural areas behind; two-thirds of new

Chapter 2--Rural Populations q43

jobs during this period were in service industries, The proportion of people who consider themselves



j g pand over 85 percent of those service jobs were inurban areas (253).

THE HEALTH OF’ RURAL

POPULATIONS

Health Status

Table 2-6 presents some information on basichealth indicators for urban and rural populations.Compared with urban residents, rural residents

overall have lower mortality rates, higher rates of chronic disease, and comparable rates of acutehealth problems.

After accounting for differences in age, sex, andracial distribution between urban and rural areas,mortality rates are lower in rural areas than in urbanareas (table 2-6) (626). Two exceptions are notable.First, infant mortality is slightly higher in rural areas.Second, deaths resulting from accidents are a

striking 40 percent higher in rural than in urbanareas.

The frequency of acute illness, and the rate of disability due to acute disease, is similar for rural andurban populations (table 2-7). Rural residents in1986 had a slightly higher incidence of acuteconditions than did urban residents, and they hadmore days in which their activities were restricted

due to these conditions, but they were less frequentlyconfined to bed as a result of acute illness (648). Aninteresting and slightly different pattern is found forthe subcategory of injury; rural residents haverelatively fewer injuries, but greater levels of injurydisability (table 2-7) (648).

Chronic disease, on the other hand, is a significantproblem in rural areas. Some common chronicconditions (e.g., heart disease, hypertension, diabe-tes, arthritis, and certain vision and hearing impair-ments) are especially prevalent in rural populations(table 2-8) (648). The high rates of chronic impair-ment in rural areas result in slightly higher reportedoverall days of activity limitation (including bothacute and chronic conditions) among rural thanamong urban residents (648).

High rates of chronic disease may explain the

urban/rural differences in self-assessed health status.

to be in only fair or poor health has been decliningin both urban and rural areas (table 2-9). Nonethe-

less, rural residents remain 20 percent more likelythan urban residents to consider themselves to be inthis category (651).

Urban and rural residents differ in their practice of preventive behaviors. Rural residents are much lesslikely than urban residents to use seatbelts regularly(table 2-10), a characteristic that is consistent withtheir higher motor vehicle accident fatality rates(649).

9Rural residents are also less likely to exercise

regularly, and they are more likely to be obese.Fewer rural residents smoke, but those who dosmoke more heavily than their urban counterparts(649).

In general, rural residents also appear to usepreventive screening services less often than dourban residents (table 2-10) (649). This differencemay be attributable to differences in access to

medical services, so it is difficult to interpret. In atleast one area of preventive medical care, however,rural residents participate on a greater level than U.S.residents as a whole. Children in rural areas are morelikely than urban children as a group, and inner citychildren in particular, to be immunized againstchildhood diseases (table 2-1 1) (651).

Health Insurance

Rural residents are less likely than urban residentsto be insured for their health care costs, particularlyby private insurance (table 2-12). For children,differences in private insuredness among urban andrural residents is slight, but rural children areconsiderably less likely to be covered by Medicaid(513). The opposite is true for nonelderly ruraladults: they are much less likely than urban adults tobe privately insured, but they have only slightlylower Medicaid coverage (513). In 1987, 17.4percent of rural residents had no health insurance(557).

10

Differences in private coverage between urbanand ma-l residents are strongly related to employ-ment. Rural residents are much less likely than urbanones to have employment-related insurance (table2-13) (557). In fact, differences in private coverage

between urban and rural populations would probably

?Motorvehicle accidents do not occur more frequently in rural than in urban areas, but when accidents do occur they are more likely to be fatal (623).lo~cludes o~y civilian and noninstitutionalized persons.


Table 2-6—Metropolitan/Nonmetropolitan Differences in Selected Health Indicators



Indicator Metro Nonmetro

Mortalitya

Infant mortality (deaths per 1,000 liveborn infants under age 1, 1987) . . . . . . .9.88 10.07

Mortality from all causes (per 1,000 population, 1980) . . . . . . . . . . . . . . . . . . . . . . .9.21

Major cardiovascular disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.61Malignant neoplasm.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.99Chronic obstructive pulmonary disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Pneumonia and influenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Motor vehicle accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21All other accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Diabetes mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Suicide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Homicide and legal intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

8.874.451.73

.25

.24

.31

.29

.16

.11

.07 Acute disease (per person per year, 1987) Number of conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1.73 1.73

Restricted activity days. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6.72 7.07

Bed days. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.98 2.95 Work-loss days (employed adults). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3.13 3.00

School-loss days (children). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3.36 3.48

Chronic disease b

(percent of respondents with activity limitation, 1988)Total limited in activities due to chronic conditions . . . . . . . . . . . . . . . . . . . . . . . . 12.6% 14.9%

Limited in major activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8.7% 10.7%Unable to perform major activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3.7% 4.3%

Limited in amount or scope of major activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . .5.0% 6.4%

Limited, but not in major activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3.9X 4.2%

Overall health, including both acute and chronic conditions Number of restricted days per person per year, 1987:

All types of restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.1 14.7

Bed days. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 6.0

Work-loss days (employed persons) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 4.9

Self-assessed health status, percent of respondents, 1988:brc

Fair or poor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.0% 11.0%Good. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.2% 24.8%

Very good or excellent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69.0% 64.3%

aMortality rates are adjusted to accommodate the different age, ‘exS and racial distributions of the urban andrural populations.

bRates in these categories are age-adjusted.cN~ers d. not add to 100 percent due to rounding.

SOURCES: Mortality rates from National Center for Health Statistics, unpublished and published data as

adjusted by Office of Technology Assessment (see refs. 626 and 650). Restricted activity data from

C.H. Norton and M.A. McManus, “Background Tables on Demographic Characteristics, Health Status andHealth Services Utilization, ” Health Services Research 23(6):725-756, February 1989; and U.S.Department of Health and Human Services, Centers for Disease Control, National Center for HealthStatistics, “Current Estimates From the National Health Interview Survey, 1987,” Vital and HealthStatistics, Series 10, No. 166, DHHS Pub. No. (PHS)88-1594 (Washington, DC: U.S. Government

Printing Office, September, 1988). Activity limitation and self-assessed health status data from1987 National Health Interview Survey data as published in U.S. Department of Health and HumanServices, Public Health Service, National Center for Health Statistics, Health, United States.1988 and Health, United States, 1989 (Washington, DC: U.S. Government Printing Office, March 1989and March 1990).

be even greater except for the fact that rural residents Rural residents have lower average incomes thanare more likely than their urban counterparts to urban residents, and lower incomes are associated inpurchase non-employment-related private coverage both rural and urban areas with lower rates of private(table 2-13). Employment-related insurance cover- insurance coverage (table 2-14)(530). At any given

age is lower for agricultural, forestry, and fishery level of income, however, poor rural residentsworkers--occupations that are predominantly rural— (incomes below 200 percent of the Federal povertythan for workers in any other industries (figure 2-4) threshold) are more likely than urban residents to(557). have some private insurance. On the other hand, for


Table 2-7—Acute Conditions Involving Activity Limitation and/or Medical Attentionin Metropolitan and Nonmetropolitan Populations 1986



in Metropolitan and Nonmetropolitan Populations, 1986

Number per 100 persons per yearaConditions Restricted activity days Bed days

Type of acute condition Metro Nonmetro Metro Nonmetro Metro Nonmetro

All acute conditions. . . . . . . . . . . . . . . . . 172.6 173.0 671.9 707.3 298.2 295.4Infective/parasitic diseases. . . . . . .22.7 24.8 73.4 78.6 35.1 36.9Respiratory conditions. . . . . . . . . . . . . 80.0 80.2 263.9 265.8 131.0 136.5Digestive system conditions. . . . . . . . 6.6 5.3 24.9 31.1 12.1 12.0Urinary conditions. . . . . . . . . . . . . . . . . 2.3 4.0 11.0 13.9 5.4 5.1

Musculoskeletal/skinconditions. . . . . . . . . . . . . . . . . . . . . . . . 5.0 2.7 29.0 28.3 10.5 6.2

Ear/eye conditions. . . . . . . . . . . . . . . . . 10.7 11.1 25.5 20.4 11.0 7.7Unspecified fever/headache

(excluding migraine). . . . . . . . . . . . . . 3.1 2.7 8.8 9.1 4.1 4.6

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.6 24.9 158.6 180.2 52.4 56.8

Delivery/conditions of

pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . 1.9 1.7 26.1 25.9 10.7 9.1Disorders of the female

genital tract . . . . . . . . . . . . . . . . . . . . . 1.6 1.1 8.0 8.0 4.1 2.5

All other acute conditions. . . . . . . . . 11.0 11.0 42.8 45.8 20.2 13.0

aThere estimates are based on a sample of fewer than 123,000 PeoPle. Estimates for low-incidence conditionsthus have a high potential rate of error.

SOURCE: U.S. Department of Health and Human Services, National Center for Health Statistics, “CurrentEstimates From the National Health Interview Survey: United States, 1987,” Vital and HealthStatistics, Series 10, No. 166. DHHS pub. No. (ET-R) 88-1594 (Washington, DC: U.S. Government Prin

Table 2-8-Selected Chronic Conditions Among Metropolitan and Nonmetropolitan Residents(prevalence per 1,000 persons, 1987)’

Type of chronic condition Metro Nonmetro

Selected circulatory conditions

Rheumatic fever with or without heart disease. . . . . . . . . . . . . . . . . . . . . . . .Heart disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

High blood pressure (hypertension) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Cerebrovascular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hardening of the arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Varicose veins of lower extremities. , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hemorrhoids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Selected respiratory conditionsChronic bronchitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hay fever or allergic rhinitis without asthma. . . . . . . . . . . . . . . . . . . . . . . .Chronic sinusitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Deviated nasal septum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Chronic disease of tonsils or adenoids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Emphysema. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Selected skin and musculoskeletal condition

Arthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gout, including gouty arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intervertebral disc disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Bone spur or tendinitis, unspecified. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Disorders of bone or cartilage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Trouble with bunions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bursitis, unclassified. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sebaceous skin cyst. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trouble with acne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Psoriasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8.0 7.677.4 99.3

113.6 135.7

11.2 11.8

9.0 12.9

30.1 33.041.7 51.6

51.8 59.239.9 40.9

97.8 86.0125.0 158.8

7.0 3.212.3 16.48.1 10.2

123.8

9.2

16.9

8.7

4.7

10.1

19.0

5.9

19.4

8.4

158.9

11.2

16.0

11.5

5.17.9

20.95.8

18.89.5

(oontinuedonnextpage)


Table 2-8-Selected Chronic Conditions Among Metropolitan and Nonmetropolitan Residents(prevalence per 1 000 persons



(prevalence per 1,000 persons, 1987)Xontinued

Type of chronic condition Metro Nonmetro

Selected skin and musculoskeletal conditions--ContinuedDermatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “ . “ ...-Trouble with dry, itching skin (unclassified). . . . . . . . . . . . . . . . . . . . . . . .Trouble with ingrown nails. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Trouble with corns and calluses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

m~t’ Visual impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Color blindness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Cataracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “ . ““ ““”

Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .“

.,Hearing impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tinnitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Speech impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Absence of extremities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Paralysis of extremities, complete or partial. . . . . . . . . . . . . . . . . . . . . . ..

Deformity or orthopedic impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Upper extremities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Lower extremities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Selected digestive conditions

Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hernia of abdominal cavity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Gastritis or duodenitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Frequent indigestion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Enteritis or colitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Spastic colon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diverticula of intestines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Frequent constipation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other selected conditions

Goiter or other disorders of the thyroid. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Anemias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Migraine headache. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neuralgia or neuritis, unspecified. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Kidney trouble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bladder disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Diseases of prostate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Diseases of female genital organs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35.816.819.916.1

31.911.522.28.2

82.0

25.29.8

6.64.4

115.565.4

12.5

50.4

18.1

18.012.522.6

7.95.9

7.6

18.7

11.4

26.7

13.7

4.1

35.83.3

12.113.3

6.818.0

38.9

22.137.1

20.3

37.911.927.310.8

108.529.310.9

7.8

7.4

118.663.3

15.7

55.2

23.1

24.010.735.29.94.4

10.0

23.3

11.7

31.6

12.2

4.9

35.85.1

20.018.4

8.7

18.2

aThese estimates are based on a sample of fewer than 123,000 people. Estimates for low-prevalence conditions

thus have a high potential rate of error.

SOURCE: U.S. Department of Health and Human Services, National Center for Health Statistics, “Current

Estimates From the National Health Interview Survey: United States, 1987,” Vital and Health

Statistics, Series 10, No. 166, DHHS Pub. No. (PHS) 88-1594 (Washington, DC: U.S. GovernmentPrinting Office, September 1988).

any given income level, poor rural residents are States are required to provide Medicaid coverage tomuch less likely than poor urban residents to be all two-parent families with incomes below State-covered by Medicaid. For farm residents, the lack of defined poverty levels. They must also cover allMedicaid coverage is striking; fewer than 6 percent pregnant women and young children with incomesof farm residents with incomes below the Federal up to 133 percent of the Federal poverty threshold,poverty threshold were covered by Medicaid in and they have the option of extending coverage to1987, compared with over 44 percent of below- those with incomes up to 185 percent of the poverty

poverty urban residents (and 38 percent of nonfarm threshold (Public Laws 99-509, 100-203). Otherrural residents) (530). A likely explanation is that poor individuals, however, still qualify for Medicaidpoor farm families tend to be two-parent households only if their incomes fall below State-definedwho are often ineligible for Medicaid. (As of 1990, eligibility levels).


Table 2-9—Proportion of Metropolitan andNonmetropolitan Residents Who Rated Their Health

Health Care Utilization



pas Fair or Poor, Selected Years, 1975-88

Year Metro Nonmetro

1975 . . . . . . . . . . . . . . . . . . . 11.2 14.21980 . . . . . . . . . . . . . . . . . . . 11.0 14.01983 . . . . . . . . . . . . . . . . . . . 10.0 12.01985. . . . . . . . . . . . . . . . . . . 9.0 12.0

1987. . . . . . . . . . . . . . . . . . . 9.0 10.8

1988. . . . . . . . . . . . . . . . . . . 9.0 11.0

NOTE: Numbers are adjusted for age (i.e., account

for differences in age distributions between metro and nonmetro areas).

SOURCES: U.S. Department of Health and HumanServices, Centers for Disease Control,

National Center for Health Statistics,

Health, United States, 1982,Health, Unit-ed States, 1986, Health, United States.

~, a n d Health, United States,1989(Washington, DC: U.S. Government PrintingOffice, 1982; December 1986; March 1989;and March 1990) .

Rural residents have less contact with physiciansthan do people in urban areas. Based on responsesfrom the National Health Interview Survey, not quitethree-fourths (74 percent) of the rural populationhave seen or telephoned a physician within the pastyear (table 2-15).11 This proportion is slightly lowerthan that for the urban population (76 percent),whose visits were also longer in duration (651).However, both urban and rural populations haveincreased the number and frequency of physician

contacts over the past two decades (table 2-16)(651).

Compared with urban residents, rural residentsare much more likely to visit a physician specializ-ing in family medicine and much less likely to visitone specializing in internal medicine (table 2-17)(447). These differences are probably largely due tothe geographic distribution of the different special-ties (see ch. 10).

Trends for visits to dentists parallel those forphysician contacts. Rural residents average fewervisits per year and are less likely to have had a recent

Table 2-10--Selected Preventive Behaviors and Risk Exposure ofMetropolitan and Nonmetropolitan Residents, 1985

Percent of adult population with behaviorBehavior Metro Nonmetro

Use seatbelts all or most of time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.9 25.5Exercise regularly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.5 35.2

Had Pap smear in past year (women only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.8 41.8Had breast exam in past year (women only). . . . . . . . . . . . . . . . . . . . . . . . . . . 51.8 45.4Had blood pressure check in past year. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85.3 83.7

Have been told have high blood pressure at least 2 times. . . . . . . . . . . . 16.8 19.4Of those with high blood pressure, taking medication. . . . . . . . . . . . . . . . 64.9 67.9

20 percent or more above desirable body weight . . . . . . . . . . . . . . . . . . . . . . 23.1 26.9

Currently smoke cigarettes. . . . . . . . . . . . . . . . . . . . . ..., . . . . . . . . . . . . . . . . . 30.3 29.4

Of smokers, smoke 25 or more cigarettes per day. . . . . . . . . . . . . . . . . . . . . 26.0 28.7Of women aged 18 to 44 giving birth in past 5 years:

Smoked in 12 months before giving birth . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.7 31.9Quit smoking when pregnant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.0 18.8Reduced smoking when pregnant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.4 38.0

Of drinkers, in the past year:Consumed 5 or more drinks in one day on at least 5 occasions. . . . . . 24.5 26.0Have driven car when had too much to drink.. . . . . . . . . . . . . . . . . . . . . . . 16.6 17.9

Exposed to at least one job-related health hazard in current job. . . . 59.5 68.7

SOURCE: U.S. Department of Health and Human Services, Centers for Disease Control, Hyatt,sville, M), National

Center for Health Statistics, unpublished data from the 1985 National Health Interview Survey,Health Promotion and Disease Prevention component.

ll~e~e&~Weadju~ted for the ~enncesfiage ~s~butlonsb e~eenuban andrural poptitions.


Table 2-1 l—immunization Status of Children Aged 1-4,1985



Percent imnunized

Vaccination Total Central cities Other metro areas Nonmetro

Polio.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55.3 47.1 58.4 58.0

Measles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60.8 55.5 63.3 61.9

Mumps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58.9 52.4 61.0 61.4

Rubella. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58.9 53.9 61.0 60.3

Diphtheria/pertussis/tetanus. . . . . . . . . .64.9 55.5 68.4 67.9

NOTE: These rates are self-reported and based on respondant’s memory.Rates reported by respondents who had

consulted vaccination records were somewhat higher.

SOURCE: Data from the United States Immunization Survey, as published in U.S.Department of Health and Human

Services, Centers for Disease Control, National Center for Health Statistics, Health, United StatesL

1989 (Washington, DC:U.S. Government Printing Office, March 1990).

Table 2-12—Percentage of Population With Health Insurance Coverage, by Age and Residence, 1984a

All ages 0-17 years 18-64 years 65+ years

Type of insurance Metro Nonmetro Metro Nonmetro Metro Nonmetro Metro Nonmetro

Private insurance . . . . . . . . . . . . . . . . . 77.2 74.7 72.6 72.3 78.9 76.2 75.0 71.9

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 13.7 ~.lb ~.4b ~.lb ~.4b 95.3 96.1

Public assistance

(Medicaid, other). . . . . . . . . . . . . . . 6.1 5.8 11.5 9.1 4.0 3.9 5.6 7.6 Military/Veterans’

Administration . . . . . . . . . . . . . . . . . . 3.2 3.9 2.7 2.9 3.1 3.9 4.5 6.1

No insurance . . . . . . . . . . . . . . . . . . . . . . 12.3 14.5 13.0 16.2 13.8 16.7 0.9 0.9

a Numbers do not add up to 100 percent, since individuals may be covered by more than one type of insurance(e.g., Medicare and private insurance).

bN@er applies t. all persons under age 65.

SOURCE: P. Ries, “Health Care Coverage by Sociodemographic and Health Characteristics, United States, 1984,” Vital and Health Statistics, Series 10, No. 162, DHHS Pub. No. (PHS) 87-1590 (Washington, DC: U.S.

Government Printing Office, November 1987).

Table 2-13—Private Insurance Coverage of Metropolitanand Nonmetropolitan Residents, 1987

Percent of population with type of health insuranceEmployment-related Other private Public coverage

Place of residence private coverage coverage only No coverage

20 largest metro areas. . . . . . . . . . . 65.0 9.7 10.2 15.1Other metro areas. . . . . . . . . . . . . . . . 67.4 8.9 9.0 14.7Nonmetro areas. . . . . . . . . . . . . . . . . . . 57.4 13.4 11.8 17.4

SOURCE: P.F. Short, A. Monheit, and K. Beauregard, A Profile of Uninsured Americans, DHHS Pub. No. (PHS) 89-3443 (Rockville, MD: U.S. Department of Health

dental visit (table 2-15) (651). Eleven percent of rural residents have never visited a dentist (651).

Hospital utilization differences between rural andurban populations are less consistent. Proportion-ately more rural than urban people are hospitalized,but their hospital stays are shorter,

12and rural

and Human Services, September 1989).

residents had only slightly more hospital days per

100 residents in 1988 (table 2-18) (651). Ruralresidents also have fewer emergency room visits

(447). As with physician contacts, however, trendsin utilization are similar; urban and rural groups

have decreased both their rates of hospital admis-

lzDa~~m~eN atio@He~~~t~iewS~eyshow~t~residen~confiuetore~fishofierhosPi t i s taystkmurbanresidents . Stice 1987,

however, nualhospitalshave actually beenrepordng slightly longer average stays than urban hospitals (seech. 5). Thereasonfor thediserepancy isunclear.

Chapter 2--Rural Populations @ 49

Figure 2-4—Health Insurance Status of Working Adults and Their Families,by Type of Industry, 1987



Mining

Manufactur ing

Transpor ta t ion,communicat ion

Financial services,insurance

Professional services

Publ ic adminis tra t ion,

m i l i t a r y

S a l e s

R e pa i r s e r v i c e s

E nte r ta i nm e nt

C ons t r uc t i on

Personal services

A gr i c u l tu r e / fo r e s t r y /

f ishing

o 10 20 30 40 50 60 70

Percent

~ E m p l o y m e n t - r e l a t e d ~ U ni ns ur e d

insurance

8 0 90 100

SOURCE: Office of Technology Assessment, 1880. Data from P.F. Short, A. Monheit, and K. Beauregard, A Profi/e ofUninsured Arrrw”&ns, DHHS pub. no. (PHS) 88-3443 (Rockville, MD: U.S. Department of Health andHuman Services, September 1989).

Table 2-14-Insurance Coverage of the Population Under Age 65, by Residence and Income, 1987

Income (percent of Federal Percent of population covered

poverty level) and residence Uninsured Medicaid Private/other

Below poverty Metro. . . . . . . . . . . . ~ . . . . . . . . . . . . . . . . . . . . . . . . .

Nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nonfarm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Farm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1OO-149%

Metro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


150-199%

Metro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nonfarm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Farm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

200% or more Metro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


37.0

38.3

38.9

32.4

36.4

31.5

32.2

24.7

26.119.8

20.215.1

10.5

10.3

10.0

14.4

44.4

35.5

38.4

5.8

13.59.29.7

3.9

6.15.3

5.6

1.3

1.10.9

1.0

0.3

18.6

26.222.7

61.8

50.1

59.358.1

71.4

67.874.974.283.6

88.4

88.8

89.0

85.3

SOURCE: Adapted from D. Rowland and B. Lyons, “Triple Jeopardy: Rural, Poor, and Uninsured,” Health ServicesResearch 23(6):975-1004, February 1989.


Table 2-15-interval Since Last Contact With Physician (1988) and Dentist (1986) forMetropolitan and Nonmetropolitan Residents



p p

Interval since last visit Number of contacts per

Residence person in past yeara

< 1 yr 1-2 yrs 2 or more yrs b

Physician contacts Metro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 77.8% 10.2% 12.0%

Nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.8 75.0% 11.5% 13.5%

Dentist visits Metro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.0 58.8% 7.1% 34.1%

Nonmetro. . . . . . . . . . . . . . . . . . . . . ., . . . . . . . 1.7 51.8% 8.9% 39.3%

NOTE: Data are adjusted for differences in age distribution between metro and nonmetro areas.

aphy5ician contact.5 include telephone,office visits,hospital visits, and other.Dentist contacts includeonly visits.

bIncludes those who have never visited a physician or dentist.

SOURCE: U.S. Department of Health and Human Services,Centers for Disease Control, National Center for HealthStatistics,Health, United States,1989 (Washington, DC:U.S. Government Printing Office, March1990).

sions and their average lengths of stay during the1980s (table 2-19)(651).

TWO SPECIAL POPULATIONS:

A CLOSER LOOK

The rural population includes many subpopula-tions, each with its own characteristics. This sectionbriefly examines two such subpopulations in greaterdetail: the rural elderly and migrant and seasonalfarmworkers.

The Rural Elderly

Population Characteristics

The great majority of people age 65 and over inthe United States--71 percent--live in metropolitancounties (633). Nonetheless, elderly persons makeup a greater proportion of the nonmetro than themetro population (13 v. 11 percent) (table 2-20)

(633). The elderly are especially prevalent in townsof 2,500 to 10,000 residents, where they make upnearly 15 percent of the population. Even the oldestages are well-represented in these towns; the propor-tion of the population that is age 85 and over, forexample, is higher in towns of this size than in anyother urban or rural category (table 2-20)(633).

Among geographic regions, the South has by farthe greatest number of rural elderly persons. One-

third of the Nation’s elderly live in this region(figure2-5), and 38 percent of them live in nonmetroareas (633). Nearly 16 percent of farm residents inthe South are elderly (table 2-21). The Midwest is a

close second with 26 percent of the U.S. elderly,over one-third of whom live in nonmetro areas. In

contrast, the West and Northeast have a relativelylow rural elderly presence (633).

The rural elderly have incomes lower than thoseof the urban elderly (table 2-22). Based on the 1980census, the median income is lower for nonmetrothan metro elderly residents, and within both groups“rural” residents (by the Census definition) havelower median incomes than “urban’’ residents. In

1979, nearly one-third of nonmetro elderly personshad incomes that were less than 125 percent of theFederal poverty threshold (633).

About 28 percent of both metro and nonmetroelderly residents live alone (table 2-23) (633).Within nonmetro areas, however, there are substan-tial differences in living arrangements. Only 16percent of elderly persons on farms live alone, forexample; 75 percent live with their spouses. Incontrast, only a little more than one-half of elderlyindividuals residing in small cities and towns livewith their spouses, while over 30 percent live alone(633). Thus, there is considerable variation withinrural areas in the home-based family and socialresources available to elderly people.

The great majority of rural elderly persons-96percent—are covered by Medicare (see table 2-12);

less than l percent lack any health insurance (513).However, the rural elderly are somewhat more likelythan the urban elderly to rely on Medicaid or otherpublic assistance, and they are less likely to have


Table 2-16-Percent of Metropolitan andNonmetropolitan Residents Who Have Had a

Physician Visit Within the Past 2 Years,

Table 2-17—Distribution of Physician Visits inMetropolitan and Nonmetropolitan Areas,

by Specialty, 1985



Physician Visit Within the Past 2 Years,Selected Years, 1964-88

by Specialty, 1985

Year Metro Nonmetro

1964 . . . . . . . . . . . . . . 82.2 78.11975. . . . . . . . . . . . . . 86.6 84.81980. . . . . . . . . . . . . . 86.6 84.71982. . . . . . . . . . . . . . 87.5 85.21985. . . . . . . . . . . . . . 85.9 84.01987. . . . . . . . . . . . . . 87.6 85.61988. . . . . . . . . . . . . . 88.0 86.5

NOTE: Numbers are adjusted for age (i.e., accountfor differences in age distributions between

metro and nonmetro areas).

SOURCES: U.S.Department of Health and HumanServices, Centers for Disease Control,

National Center for Health Statistics,Health, United States, 1982, Health, Unit-

ed States,1986, Health, United States.

g, a n d Health, United States, 1989

(Washington, DC: U.S. Government PrintingOffice, 1982; December 1986; March 1989;

and March 1990).

private insurance to supplement their Medicarepolicies (513).

Health Status and Health Care Utilization

Rural elderly residents are more likely than urbanelderly residents to have chronic health impairments(41 v. 36 percent) (table 2-24) (645), and they are

more likely to consider themselves in only fair orpoor health (table2-25).It appears that disability dueto acute illness is lower among rural than amongurban elderly residents, because when both chronicand acute causes of illness are considered, ruralelderly residents actually report slightly fewer totaldays of disability (table 2-26) (645).

Health care utilization trends for the rural elderlyparallel many of the trends for the urban elderly andfor the United States as a whole. For example, thenumber of physician visits per rural elderly personper year rose between 1983 and 1987, and within theelderly group the frequency of visits rises with age(table 2-27) (645). Similarly, the proportion of therural elderly population who had seen a physicianwithin the past year has risen overtime (table 2-28).Nevertheless, physician utilization among the ruralelderly continues to lag behind utilization by the

Physician specialty Metro Nonmetro

General and family practice. . . . .

Internal medicine. . . . . . . . . . . . . . .Pediatrics. . . . . . . . . . . . . . . . . . . . . .Obstetrics/gynecology. . . . . . . . . . .General surgery. . . . . . . . . . . . . . . . .

Orthopedic surgery. . . . . . . . . . . . . .Ophthalmology. . . . . . . . . . . . . . . . . . .

Other. . . . . . . . . . . . . . . . . . . . . . . . . . .

Total. . . . . . . . . . . . . . . . . . . . . . . . .

11.9%51.76.04.72.0

2.63.4

17.4

100%

52.6%10.07.15.96.73.13.6

11.1100%

SOURCE: 1985 National Ambulatory Medical Care Survey

data as cited in C.H. Norton and M.A. Mc-Manus, “Background Tables on DemographicCharacteristics, Health Status and HealthServices Utilization, ” Health ServicesResearch 23(6):725-756, February 1989.

urban elderly in nearly every category (645). Thislower utilization cannot be adequately explained byless illness and disability among the rural elderly. Itis consistent, however, with relatively more difficultphysical and economic access to physicians forresidents of rural areas.

Hospital utilization patterns for rural elderlypersons, on the other hand, are not so easilyexplained by lessened access to hospital facilities.Rural elderly individuals report more hospital dis-charges, but substantially shorter average lengths of

stay, than do their urban counterparts (table 2-29)(645). This pattern seemingly conflicts with theimage of hospital scarcity in rural areas, and itcannot be explained by a higher availability of homecaregivers for the rural elderly (since just as manynonmetro as metro residents live alone).

A study of Medicare beneficiaries in five States(Alabama, California, Illinois, Montana, and Texas)

lends some insight into the enigma. In this study,Medicare hospital admissions decreased 18 percentfor urban beneficiaries and a dramatic 22 percent forrural beneficiaries between 1984 and 1986(134).

13

Not only did the rural trend follow the urban trend,but the greater decline in admissions for ruralbeneficiaries suggests the possibility that ruralpatients’ hospital utilization is becoming more likethat of urban patients. Furthermore, when admis-sions were categorized by type, by far the greatest

13~e~efiWe~mefora~~~iom adju~t~fordifferences~ ~eandsexdis~butio~. un~just~differenmsw~e –llpercentforurbanand -17

percent for rural beneficiaries.




Table 2-19-Trends in Hospital Utilization byMetropolitan and Nonmetropolitan Residents,

Selected Years, 1964-88

Health Care Status and Utilization

There are few routinely collected national data on



Year Metro Nonmetro

Hospital discharges (number per 100 parsons per year)1964 . . . . . . . . . . . . . . . . . . 10.8 11.31975 . . . . . . . . . . . . . . . . . . 11.9 13.61980 . . . . . . . . . . . . . . . . . . 11.0 14.11985. . . . . . . . . . . . . . . . . . 10.1 11.71987. . . . . . . . . . . . . . . . . . 9.3 10.91988. . . . . . . . . . . . . . . . . . 8.7 11.4

Average length of hospital stay (days)1964. . . . . . . . . . . . . . . . . . 9.4 7.7

1975. . . . . . . . . . . . . . . . . . 7.8 6.81980. . . . . . . . . . . . . . . . . . 8.3 7.51985. . . . . . . . . . . . . . . . . . 7.2 6.81987. . . . . . . . . . . . . . . . . . 7.1 5.81988. . . . . . . . . . . . . . . . . . 6.9 6.0

Total hospital inpatient days (per 100 population)

1964. . . . . . . . . . . . . . . . . . 101.5 87.21975. . . . . . . . . . . . . . . . . . 104.3 105.71980. . . . . . . . . . . . . . . . . . 91.1 105.81985. . . . . . . . . . . . . . . . . . 73.3 79.31987. . . . . . . . . . . . . . . . . . 65.6 63.41988. . . . . . . . . . . . . . . . . . 60.6 68.2

NOTE: Numbers are adjusted for age (i.e., accountfor differences in age distributions between

metro and nonmetro areas).These data are based on interviews and thus include only patients who were discharged alive.

SOURCES: U.S. Department of Health and HumanServices, Centers for Disease Control,

National Center for Health Statistics,Health, United States, 1982, Health, Unit-e d S t a t e s ,1986, Health, United States<

1988 a n d Health, United States,J 1989(Washington, DC: U.S. Government PrintingOffice, 1982; December 1986; March 1989;and March 1990).

(181). If ratios from the late 1970s still hold true,

approximately 3O percent of these farmworkers (1.2

million) are migrants (726).

Farmworkers are culturally diverse. In the East,

many are from Puerto Rico, Jamaica, and Haiti. In

the Midwest and West, the great majority of migrant

farmworkers are Hispanic. Native Americans make

up a substantial proportion of the farmworker

population in the west and southwest (726).

The living conditions of migrant and seasonalagriculturalworkers are typically poor. According to

one source, the average annual family income in1983 for migrant workers was about $9,000, signifi-cantly below the Federal poverty threshold ($11,000for a family of four) (420).

the health status of farmworkers; most that do exist

are from farmworkers seen in federally funded migrant health centers (MHCs). Although these

clinics serve only an estimated 523,000 persons per

year-about 13 percent of the target population

(181)--they are a vital source of health care services

to migrant and seasonal farmworkers and the corner- q

stone of Federal policies to promote health services

to this community.

A 1981 survey of MHCs found that obstetrics and

hypertension were the most frequent reasons for

visits to these clinics in 1979 and 1980 (table 2-30)

(256). A 1984 survey of migrant farmworker fami-

lies identified some major health problems in tie

population (table 2-31), including:

q

q

q

q

ailments (e.g. urinary tract infections) associ-

ated with poor sanitation and overcrowdedliving conditions (e.g., lack of toilets, hand-

washing facilities, potable drinking water);a prevalence of parasitic infections that aver-aged 20 times greater than in the generalpopulation;acute and chronic illnesses related to pesticidepoisoning; andhazards affecting the health of pregnant womenand children(605).

Most of the workers and their families soughtmedical care mainly for acute illnesses.

In 1988, 118 MHCs operated clinics in 33 Statesand Puerto Rico (181) The number of MHCs and thenumber of patient encounters (visits) at those centershave both increased slightly in recent years (table2-32); in 1988, there were over 4.8 million encoun-ters (about 41,000 per center) (181). Encountersspecifically from migrant and seasonal farmworkers

increased nearly three times as fast as total patientencounters. In 1988, farmworker encounters repre-sented about 35 percent of the total; the number of encounters per farmworker averaged 3.4. Among theStates, California has both the largest total numberof migrant and seasonal farmworkers and the largestshare of Federal MHC funds (table 2-33) (181).

SUMMARY AND CONCLUSIONS

Although “rural” is a term with considerableintuitive meaning, two commonly used definitionsof the term describe somewhat different populations.


Table 2-20-Age Distribution of Urban and Rural Elderly Residents, 1980

Urban residents Rural residents




Percent of total Nonurbanized area

population in All United Urbanized 10,000 2,500- Farm Metro Nonmetroarea that is: States All area and over 10,000 All residents areas areas

Age 65 or over.. . ...........11.3 11.4 10.9 12.9 14.7 10.9 12.7 10.7 13.065-74 . . . . . . . . . . . . . . . . . . . . . 6.9 6.9 6.6 7.5 8.5 6.9 8.6 6.5 7.975-84 . . . . . . . . . . . . . . . . . . . . . 3.4 3.5 3.3 4.1 4.7 3.1 3.3 3.2 3.985 and over. . . . . . . . . . . . . . . 1.0 1.0 0.9 1.3 1.5 0.9 0.8 0.9 1.1

SOURCE: U.S.Department of Commerce, Bureau of the Census, 1980 Census:General Social and EconomicCharacteristics, vol. 1 (Washington, DC:U.S. Government Printing Office, September 1981).

Most national statistical information is available bythe county-based metro/nonmetro designations, be-cause county borders are relatively stable and enableconsistent comparisons over time. Unfortunately,simple metro/nonmetro comparisons often blur im-portant differences among populations that affect theperception of their health and other characteristics.Good information on health status and health

programs is vital to the evaluation of programs, butwhen only metro/nonmetro distinctions are ana-lyzed, information may be insufficient to assesshealth improvements adequately.

In general, the picture of the rural population overthe past decade has been one of sluggish and erraticeconomic and population growth. Improvements inthe standard of living of rural residents havegenerally lagged behind those of urban residents,

and rural poverty has become a more pressingproblem. These generalities obscure crucial regionaland local differences. The heavy dependence of many regions and rural communities on singleindustries make them especially vulnerable to eco-nomic changes affecting those industries. Countieseconomically dependent on agriculture fared badlyduring the early 1980s, for example, while ruralcounties that serve as retirement communities have

been relatively successful at improving their eco-nomic well-being. The South continues to be areservoir of rural poverty.

Despite persistent differences in important factorssuch as income and education, rural residents exhibitfewer consistent indicators of poor health than mightbe expected. Mortality rates are lower in rural thanin urban areas, the most spectacular exception being

for accidental deaths. However, rural populationsare characterized by chronic impairments and poorself-perceptions of health to a substantially greaterextent than urban populations. The relatively high

prevalence of chronic disability and fatal injuries,combined with a lower prevalence of some keypreventive health behaviors (such as seatbelt use),suggests that preventive and therapeutic healthprograms addressing these areas might be particu-larly appropriate to rural populations.

Rural residents have relatively low overall utiliza-tion rates for hospitals and physicians, despite their

high number of hospital admissions. Lower ruralincomes, combined with relatively low insurancecoverage of nonelderly rural populations, suggestthat these utilization patterns may be partiallyattributable to financial access. The very low rates of Medicaid coverage among poor rural residents,especially farm residents, is of particular concern.Interestingly, despite continued limitations in finan-cial access to health care, trends in rural health care

utilization over time have paralleled urban patterns,albeit at a lower level. Physician visits have in-creased, and inpatient hospital use has decreased, forboth groups.

The elderly are disproportionately represented innonmetro counties, with the South and Midwesthaving particularly high concentrations of elderlyrural residents. The broad brush of Medicare has

resulted in few elderly persons without any healthinsurance, but rural elderly residents are less likelythan their urban counterparts to hold private insur-ance supplements to their Medicare policies. Thehealth care utilization patterns of the rural elderlyparallel those of rural residents generally, with fewerphysician visits but more hospitalizations--particularlyshort hospitalizations-than characterize their urbancounterparts.

Although their exact distribution across metro andnonmetro areas is unknown, migrant and seasonalfarmworkers are another population of particular


Figure 2-5—Regional Distribution of Urban and Rural Elderly Residents, 1980

100100 -- -—



90

8 0

70

80

50

40

30

20

10

0

81.3

90

67.3

84.5

80

70

60

50

40

30

20

10

0

62

38

118.8 (

,,

Nonmetro

15.5

1.5~ —-1-Farm

WEST

+Urban Rural MetroUrban Rural Farm Metro Nonmetro

SOUTH

No

1 0 0 — —~_ -100

90

I 80

70

60

50

40

30

9 0 -

8 0

7 0 -

6 0 -

5 0 -

4 0 -

30

1

2 0 -

10

0

82.1

—-7

83.9

–T–––

70.4

63.8

36.2

Nonmetro

29.6

17.9

--E

Rural

16,1 20 — ,I I

1--

10

I

T ’ 0Nonmetro

0.6‘ - ~ - - — T

– 1Urban Farm Metro Urban Rural Metro

NORTHEAST MIDWEST

SOURCE: Office of Technology Assessment, 1990. Data from U.S. Department of Commerce, Bureau of the Census, 1980 Census: Genera/ Soual and Economic Characteristics, vol. (Washington, DC: U.S. Government Printing Office, 1981).

concern to rural health services. The health of these Health status and financial access are only two of roughly 4 million farmworkers is greatly affected by the major contributors to health care utilization. Adiseases related to their living and working condi- third potential contributor--availability of healthtions. Federally funded MHCs appear to be a very

resources-is the topic of most of the remainder of important source of care to this population, eventhis report.

though only a relatively small proportion of farm-workers seek care in these centers.

-


Table 2-21—Percent of Urban and Rural Persons Who Are Elderly, by Region, 1980

Entire Urban Rural residents Metro Nonmetro



Entire Urban Rural residents Metro Nonmetro

region residents All Farm areas areas

South . . . . . . . . . . . . . . . . . . . . . 11.2 11.3 11.1 15.8 10.4 12.9 West. . . . . . . . . . . . . . . . . . . . . . 9.9 10.0 9.6 10.2 9.8 10.6 Northeast. . . . . . . . . . . . . . . . . 12.3 12.8 10.6 9.8 12.2 13.2 Midwest. . . . . . . . . . . . . . . . . . . 11.4 11.3 11.4 11.6 10.2 14.1

SOURCE: U.S. Department of Commerce, Bureau of the Census, 198(J Census:General Social and Economic

Characteristics, vol. 1 (Washington, DC: U.S. Government Printing Office, September 1981).

Table 2-22—Income Characteristics of Elderly Urban and Rural Residents (age 65 and older), 1979

Metro Nonmetro

Total Urbana

Rurala

Total Urbana

Rurala

Median income. . . . . . . . . . . . . . . . . . . . . . . . . . $13,421 $13,775 $11,426 $10,157 $11,165 $9,633

Percent of elderly with incomes

below Federal poverty level. . . . . . . . . . 12.4% 12.1% 15.2% 20.7% 18.4% 22.2%

Percent of elderly with incomes

below 125% of Federal poverty level.. 20.7% 20.3% 23.8% 30.9% 28.5% 32.6%

aAs defined by the Census Bureau.SOURCE: U.S. Department of Comnerce, Bureau of the Census, 198(I Census: General Social and Economic Charac-

teristics, vol. 1 (Washington, DC: U.S. Government Printing Office, September 1981.)

Table 2-23-Living Characteristics of Elderly Urban and Rural Residents, 1980


Nonurbanized area

Living All United Urbanized 10,000 2,500- Farm Metro Nonmetroarrangement States All area and over 10,000 All residents areas areas

Living with others. . . . . . . . 66.5 64.8 65.9 60.2 60.8 71.6 84.2 66.3 66.3

Head of household/

living with spouse. . . . 55.6 53.3 53.5 52.1 53.3 62.4 74.6 54.6 58.3Living with other

relatives. . . . . . . . . . . . . 8.8 9.2 10.0 6.3 5.9 7.7 8.6 9.8 6.5Living with non-

relative . . . . . . . . . . . . . 2.1 2.3 2.4 1.8 1.6 1.5 1.0 2.3 1.5

Living alone. . . . . . . . . . . . . . 27.7 28.8 28.3 31.3 30.6 24.4 15.8 27.6 27.9

Living in group

quarters . . . . . . . . . . . . . . . . . 5.8 6.4 5.8 8.5 8.6 4.1 -- 5.8 5.8

SOURCE: U.S. Department of Commerce, Bureau of the Census, 1980 Census: General Social and EconomicCharacteristics, vol. 1 (Washington, DC: U.S. Government Printing Office, September 1981).


Table 2-24—Percent of Metropolitan and Nonmetropolitan Elderly Limited in Activity Due toChronic Conditions, By Age, 1987

Metro Nonmetro



Metro>65 65-74 > 75 >65 65-74 > 75

Total with limitation of activity. . . . . . . . . . . . . . . . . . 36.2 33.5 40.7 41.0 38.2 45.3

Experienced limitation but not in major

activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . , . . . 13.6 11.9 16.5 17.4 15.3 20.7

Limited in amount or kind of major activity. . . . . . . . 12.7 11.2 15.1 13.2 11.5 15.9

Unable to carry out major activity . . . . . . . . . . . . . . . . . 9.9 10.4 9.0 10.3 11.3 8.6

SOURCE: U.S. Department of Health and Human Services, Centers for Disease Control, National Center for Health

Statistics, Hyattsville, MD, unpublished data from the National Health Interview Survey provided by

D. hkuc, Oct. 4, 1989.

Table 2-25—Self-Assessed Health Status Among the Metropolitan and Nonmetropolitan Elderly, 1987

Excellent Very good Good Fair or poor

Metro residentsAge 65 and over. . . . . . . . . . . . . . . . . . . . . 16.3% 21.3% 32.6% 29.8%Age 65-74 . . . . . . . . . . . . . . . . . . . . . . . . . 17.7 22.2 32.8 27.2Age 75 and over. . . . . . . . . . . . . . . . . . . 14.0 19.6 32.3 34.0

Hcmmetro residentsAge 65 and over. . . . . . . . . . . . . . . . . . . . . 13.1 20.1 33.4 33.4

Age 65-74 . . . . . . . . . . . . . . . . . . . . . . . . . 13.9 19.8 35.3 31.0Age 75 and over. . . . . . . . . . . . . . . . . . . 11.8 20.5 30.6 37.2



D. hkuc, Oct. 4, 1989.

Table 2-26—Rate of Restricted Activity Days Among the Metropolitan and Nonmetropolitan Elderly Due toAcute and Chronic Conditions, by Age, 1987 (number of days per person)

65 and over 65-69 70-74 75 and over

Restricted activityAll metro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.4

Central city.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.8

Noncentral city. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.7

All nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.2

Nonfarm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.7Farm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.4

confined to bedAll metro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.3

Central city. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.9

Noncentral city. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.0

All nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.2Nonfarm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.3Farm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.5

25.1

28.3

22.9

24.1

24.3

21.8

11.8

13.5

10.6

10.4

10.6

7.8

31.3

36.0

27.6

30.7

32.2

13.3

13.8

15.1

12.7

12.7

13.6

2.7

34.636.7

32.7

35.1

35.036.9

16.9

18.3

15.6

15.9

15.3

26.1



G. Hendershot, November 1989.

20-810 0 - 90 - 3 QL3


Table 2-27—Utilization of Physician Services byMetropolitan and Nonmetropolitan Elderly Persons:

Average Annual Number of Physician Visits PerPerson, 1983 and 1987



Physician visits per persona

1983 1987

Age group Metro Nonmetro Metro Nonmetro

65 and over. . . . . . 7.9 7.1 9.1 8.2

65-74. .,....... 7.5 6.8 8.8 7.3

75 and over. . . . 8.5 7.7 9.7 9.7

aData for lg83 include only visits for which ‘he

location of visit is known. Visits in 1987 includethose in unspecified places as well.

SOURCE: U.S. Department of Health and Human Ser-vices, Centers for Disease Control, Nation-

al Center for Health Statistics, Hyatts-

ville, MD, unpublished data from NationalHealth Interview Survey provided by D.Makuc, Aug. 28, 1989.

Table 2-28—Utilization of Physician Services by Metropolitan and Nonmetropolitan Elderly Persons,1964, 1982, and 1987

Percent of population with visits within past year

1964 1982 1987

Age group Metro Nonmetro Metro Nonmetro Metro Nonmetro

65 and over. . . . . . . . . . . . . . . . . . 69.3 70.4 83.0 80.7 85.5 83.6

65-74 . . . . . . . . . . . . . . . . . . . . . . 68.8 68.9 81.4 78.0 84.1 80.7

75 and over. . . . . . . . . . . . . . . . 70.4 73.2 85.7 85.1 87.7 88.1



D. Makuc, Aug. 28, 1989.

Table 2-29—Hospital Utilization by Elderly Metropolitan and Nonmetropolitan Persons, 1987a

Discharges Average Days of care

(Per 100 population) length of stay ( Per 100 population)Age group Metro Nonmetro Metro Nonmetro Metro Nonmetro

65 and over. . . . . . . . . . . 25.4 26.2 8.8 6.9 221.9 181.0

65-74 . . . . . . . . . . . . . . . 22.4 23.6 8.7 6.9 194.8 162.275 and over. . . . . . . . . 30.1 30.2 8.8 7.0 265.7 210.2

aData ar e based on interviews and thus do not include hospital stays of persons who were not discharged alive.

Metro and nonmetro status refers to residence of respondent, not location of hospital used.

SOURCE: Unpublished data from the National Health Interview Survey, provided by D. Makuc, U.S. Department ofHealth and Human Services, Centers for Disease Control, National Center for Health Statistics,Hyattsville, MD, Aug. 28, 1989.


Table 2-30—Most Frequent Diagnoses Reported by60 Federally Funded Migrant Health Centers, 1980

a

Table 2-31—Major Illnesses Reported by MigrantFarmworker Families, 1984

Number ofDiagnosis/reason for visit encounters

Percent of families

reporting at least one



g /

Obstetrics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36,125Hypertension. . . . . . . . . . . . . . . . . . . . . . , . . . . 32,067Acute upper respiratory infection. . . . . . 30,364Otitis media. . . . . . . . . . . . . . . . . . . . . . . . . . . 17,931Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17,889Diabetes mellitus. . . . . . . . . . . . . . . . . . . . . . 17,266Urinary tract infection. . . . . . . . . . . . . . . . 10,705Family planning . . . . . . . . . . . . . . . . . . . . . . . . 6,827

Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,322

Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,132

Dermatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,727

Heart disease. . . . . . . . . . . . . . . . . . . . . . . . . . 2,671Gastroenteritis. . . . . . . . . . . . . . . . . . . . . . . . 2,594

a Not all of the 60 centers responding to the survey

had complete data.

SOURCE: W. Hicks, “Migrant Health: An Analysis, ”

Primary Care FOCUS, publication of theNational Association of Community HealthCenters, July/August 1982, as cited in V.A.

Wilk, The Occupational Health of Mi~rant and

Seasonal Farmworkers in the United States(Washington, DC: Farmworker Justice Fund,

Inc., 1986).

reporting at least one

member with specifiedillness during

Illness the past yeara

Eye problems. . . . . . . . . . . . . . . . . . . . . .

Depression. . . . . . . . . . . . . . . . . . . . . . . .

Anemia. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Arthritis. . . . . . . . . . . . . . . . . . . . . . . . .

High blood pressure. . . . . . . . . . . . . . .

Stillbirth. . . . . . . . . . . . . . . . . . . . . . . .

Kidney problems. . . . . . . . . . . . . . . . . . .

Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . .

Problems during pregnancy. . . . . . . . .Asthma. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intestinal parasites. . . . . . . . . . . . . .

Deafness. . . . . . . . . . . . . . . . . . . . . . . . . .

Heart problems. . . . . . . . . . . . . . . . . . . .

Ulcers. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sunstroke. . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . .

Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . .

Pesticide poisoning. . . . . . . . . . . . . . .

Liver damage. . . . . . . . . . . . . . . . . . . . . .

‘Lazy eye". . . . . . . ., . . . . . . . . . . ..., .

Tuberculosis. . . . . . . . . . . . . . . . . . . . . .

Infertility. . . . . . . . . . . . . . . . . . . . . . .

Sickle cell anemia. . . . . . . . . . . . . . . .

Alcoholism. . . . . . . . . . . . . . . . . . . . . . . .

Polio. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35.2

23.1

21.7

18.9

16.8

16.2

14.8

14.3

13.412.5

11.3

11.2

11.2

9.4

9.4

7.5

4.7

4.7

4.3

3.8

3.8

3.8

3.2

2.9

1.9

0.9

asurvey included 10 9 migrant farmworker families.

SOURCE: R.T. Trotter, “Project HAPPIER Final Reportof Survey Results: Migrant Family Survey,”Sept. 21, 1984, as cited in V.A. Wilk, The

Occupational Health of Migrant and Seasonal

Farmworkers in the United States (Washing-ton, DC: Farmworker Justice Fund, Inc.,1986).

Table2-32—Utilization of Federally Funded Migrant Health Centers, 1984-88

Percent change,

1984 1985 1986 1987 1988 1984-88

Number of centersa

. . . . . . . . . . . . 114 120 125 119 118b

3.5

Total center encounters

(in millions). . . . . . . . . . . . . . . 4.52 4.08 4.64 4.72 4.85 7.2

Total farmworker encounters

(in millions). . . . . . . . . . . . . . . 1.42 1.43 1.54 1.67 1.70 19.9

Estimated total farmworker

encounters per person . . . . . . 3.36 3.36 3.43 3.50 3.40 1.2

aNu~er of health centers Kecelvlng Federal funds authorized under Section 329 of the Public Health Service

Act.b

ofthe 118 centers, 117 were reported.

c

Migrant and seasonal farmworkers only.

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau ofHealth Care Delivery and Assistance, unpublished data provided by J. Egan, Rockville, MD, March

1990.


Table 2-33-State Distribution of Migrant and Seasonal Farmworkers (MSFW) andFederal Migrant Health Center (MHC) Funds, Fiscal Year 1988

MSFW Percent MSFW MSFW users of MHCS Impact MHC funds , 1988



State population population Number Percent ratio Dollars

a

Percent

Alabama. . . . . . . . .

Alaska. . . . . . . . . .

Arizona. . . . . . . . .

Arkansas. . . . . . . .

California. . . . . .

Colorado. . . . . . . .

Connecticut. . . . .Delaware. . . . . . . .

Florida. ..., . . . .

Georgia. . . . . . . . .

Hawaii. . . . . . . . . .Idaho. . . . . . . . . . .

Illinois. . . . . . . .

Indiana. . . . . . . . .

Iowa. . . . . . . . . . . .

Kansas. . . . . . . . . .

Kentucky. . . . . . . .

Louisiana. . . . . . .

Maine. . . . . . . . . . .

Maryland. . . . . . . .

Massachusetts. . .

Michigan. . . . . . . .

Minnesota. . . . . . .Mississippi. . . . .

Missouri. . . . . . . .

Montana. . . . . . . . .

Nebraska. . . . . . . .

Nevada. . . . . . . . . .

New Hampshire. . .

New Jersey. . . . . .

New Mexico. . . . . .

New York. . . . . . . .

North Carolina. .

North Dakota. . . .

Ohio. . . . . . . . . . . .Oklahoma. . . . . . . .

Oregon. . . . . . . . . .Pennsylvania. . . .

Puerto Rico. . . . .

Rhode Island. . . .

South Carolina. .

South Dakota. . . .

Tennessee. . . . . . .

Texas. . . . . . . . . . .

Utah. . . . . . . . . . . .

Vermont.. . . . . . . . .

Virginia. . . . . . . .Washington. . . . . .

West Virginia. . .

Wisconsin. . . . . . .

Wyoming . . . . . . . . ..-—-_-——--—————---

6,483 0.2-— b 0.0

31,795--

1,362,53449,347

9,4215,397

435,373

93,604--

119,968

20,8407,716

34,23018,533

--

--

8,660

4,267

7,813

67,227

13,344-—

20,324

13,026

18,756--

726

13,522

9,255

30,811

344,944

15,000

11,621——

128,56424,711

231,889459

18,560--

6,571

500,138

8,983

1,785

15,079442,444

2,700

8,199

6,800

0.8

0.0

32.7

1.2

0.2

0.1

10.4

2.2

0.02.9

0.5

0.2

0.8

0.4

0.0

0.0

0.2

0.1

0.2

1.6

0.30.0

0.5

0.3

0.5

0.0

0.0

0.3

0.2

0.7

8.3

0.4

0.30.0

3.1

0.6

5.6

0.0

0.4

0.0

0.2

12.0

0.2

0.0

0.410.6

0.1

0.2

0.2.—_--—--—--———

————

9,370--

107,267

26,374--

5,027

77,173

1,598—-

12,935

5,894

5,022

1,734

925—-

——

230-—

100

26,676

9,254—-

-—

3,641

1,422-—

--

3,314

1,081

3,617

25,353--

3,4831,597

22,682

5,126

73,271—-

4,050-—

741

42,116

2,957-—

--31,247

2,825

2,193

2,754

0.0

0.0

1.8

0.0

20.55.0

0.0

1.0

14.8

0.3

0.02.5

1.1

1.0

0.3

0.2

0.0

0.0

0.0

0.0

0.0

5.1

1.80.0

0.0

0.7

0.3

0.0

0.0

0.6

0.2

0.7

4.9

0.0

0.70.3

4.3

1.0

14.0

0.0

0.8

0.0

0.1

8.1

0.6

0.0

0.06.0

0.5

0.4

0.5

0.0%

0.0

29.5

0.0

7.9

53.5

0.0

93.1

17.7

1.7

0.010.8

28.3

65.1

5.1

5.0

0.0

0.0

2.7

0.0

1.3

39.7

69.40.0

0.0

28.0

7.6

0.0

0.0

24.5

11.7

11.7

7.4

0.0

30.00.0

17.6

20.7

31.6

0.0

21.8

0.0

11.3

8.4

32.9

0.0

0.07.1

104.6

26.8

40.5

Total 4,171,419 100.0% 523,049

----

650,011--

6,607,069

2,017,909--

881,440

5,947,653

143,258--

465,026

454,985

460,870

171,961

165,218——

——

——

--

78,000

2,535,192

863,660——

130,346

250,172

224,475-—

--

182,710

104,197

381,164

1,477,681——

540,000193,468

1,449,900

601,000

3,595,126--

558,008-—

125,000

5,221,106

289,825—-

--2,658,441

300,000

364,293

161,756

0.0

0.0

1.6

0.0

16.4

5.0

0.0

2.2

14.8

0.4

0.01.2

1.1

1.1

0.4

0.4

0.0

0.0

0.0

0.0

0.2

6.3

2.20.0

0.3

0.6

0.6

0.0

0.0

0.5

0.3

1.0

3.7

0.0

1.30.5

3.6

1.5

8.9

0.0

1.4

0.0

0.3

13.0

0.7

0.0

0.06.6

0.8

0.9

0.4- --— --——————- -—-—__-———-. .— -- --———————- . . --———————-100.0% 12.54.% 40,250,920 100.0%

aThe total funding shown does not reflect multistate, hospital, and miscellaneous awards, which equalled

$3,215,080. The grand total for fiscal year 1988 was $43,466,000.b

Dashes indicate that none were identified by the State.

SOURCE: J. Egan, U.S. Department of Health and Human Services, Health Resources and Services Administration,Office of Migrant Health, personal communication, March 1990.



Chapter 3

Federal Programs AffectingRural Health Services



CONTENTSPage

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61HEALTH CARE FINANCING PROGRAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Exceptions to Medicare and Medicaid Rules for Rural Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

HEALTH BLOCK GRANT PROGRAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Maternal and Child Health Block Grant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Preventive Health and Health Services Block Grant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Alcohol, Drug Abuse, and Mental HealthServices Block Grant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

PROGRAMS TO AUGMENT RURAL HEALTH RESOURCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Health Personnel Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....,, . . . . . 77Primary Care Facilities and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Acute-Care Facilities and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

RURAL HEALTH POLICY AND RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 82Agency for Health Care Policy and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Office of Rural Health Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Boxes Box Page

3-A. Summary of Formula for Medicare Payments to Hospitals for Inpatient Care, January 1990. 643-B. Qualifying Criteria for Rural Referral Centers and Sole Community Hospitals . . . . . . . . . . . . 663-C. Swing Bed Certification Requirements for Rural Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733-D. Rural Health Clinic Certification Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

TablesTable Page

3-1. Appropriations for Selected Federal Programs Affecting Rural Health Services: Fiscal Years1980, 1988, 1989, and 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 62

3-2. Summary ofMajor Medicare Benefits, Copayments, and Coverage Limitations, 1990 . . . . . . 633-3. Some Basic Eligibility Characteristics of State Medicaid programs . . . . . . . . . . . . . . . . . . . . . . . 693-~. Services Covered Under Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71q-5. State Medicaid Hospital and Physician Reimbursement Methods, Fiscal Year 1987 . . . . . . . . 72

Chapter 3

Federal Programs Affecting Rural Health Services



INTRODUCTION

Federal programs affect the availability and provi-sion of rural health services in a multitude of ways.This chapter presents a brief overview of majorhealth programs that fall into four categories:

1.

2.

3.

4.

Programs whose primary function is to pay for

direct health services-specifically, Medicare

and Medicaid. These two programs fund asubstantial amount of rural health care, andconsequently their policies can have a largeeffect on the availability and provision of services.

1

Federal block grant programs that provide

States with resources to fund and provideservices. Three major programs that affecthealth care generally-the Maternal and Child

Health block grant, the Preventive Health andHealth Services block grant, and the Alcohol,Drug Abuse, and Mental Health block grant—are described here.

Federal programs whose primary purpose is

to augment the health resources mailable to

underserved areas and populations. Most of these programs, which augment personnel,facility, and planning resources, are adminis-tered through the U.S. Department of Healthand Human Services’ (DHHS’s) Health Re-sources and Services Administration (HRSA).

Health policy and research. The FederalGovernment has recently undertaken to con-solidate some health research and policyefforts, including efforts focused on ruralhealth. Notable current efforts include those of

the Agency for Health Care Policy and Re-search and the Office of Rural Health Policy.

Table 3-1 presents recent appropriation figures forblock grant and health resources programs.

HEALTH CARE FINANCINGPROGRAMS

Medicare

Medicare is a Federal health insurance programthat serves approximately 34 million elderly anddisabled persons and has an estimated 1990 outlayof $108 billion (146,201). It is divided broadly into

two parts, distinguished by their financing mecha-nisms. Part A (Hospital Insurance) is financedthrough Social Security taxes and covers hospitalinpatient, skilled nursing facility, and home healthservices. Part B (Supplementary Medical Insurance)is financed through a monthly premium and generalrevenues and covers outpatient and physician serv-ices and nonhospital medical equipment. Table 3-2summarizes Medicare’s basic medical care coverage

and the basic limits and copayments it imposes.

Because Medicare pays for the health care serv-ices used by a large proportion of the population, andbecause its payment and regulatory policies areoften used as models by other third-party payers, itcan have a major effect on health care providers. Inaddition, Medicare explicitly distinguishes betweenrural and urban providers when paying for services.

The discussion below briefly describes some of these payment policies.

Hospital Inpatient Payment

Basic Payment Methods--Hospitals are reim-bursed for inpatient services provided to Medicarebeneficiaries according to a prospective paymentsystem (PPS), under which a hospital is paid a freedamount for treating each patient (Public Law 98-

21).

2

This payment amount is linked to the primarydiagnosis of the patient and the diagnosis-relatedgroup (DRG) to which the patient is assigned. Thesystem is based on averages and is intended to fosterefficiency; if a hospital is able to keep its own costs

1A n~ber of ~~er Fede~~ pro-s ~so ffince or provide direct he~~ care (e.g., tie Department of Veteram Affai rs and th e Civilian Herdth and

Medical Program of the Uniformed Services). However, their policies have much less impact on rural health services and are thus not described here.The Indian Health Service also provides and funds services to the significant proportion of the rural population who are Native Americans; this program k the topic of a previous OTA report and k not described in this chapter (616).

~ertain specialty hospitals (psychiatric, cancer, rehabilitation and children’s hospitals) are exempt from the prospective payment system.

--41–



Chapter 3-Federal Programs Affecting Rural Health Services q 63

Table 3-2-Summary of Major Medicare Benefits, Copayments, and Coverage Limitations, 1990

Benefit Copayments and coverage limitations

P t A b fit



Part A benefitsHospital acute inpatient care s

m

s

s

Psychiatric inpatient care m

Skilled nursing facility care s

s

q

s

Home health servicesb

Hospice services

s

s

m

s

s

s

s

s

Part B benefitsPhysician and other medical s

services

s

s

Hospital outpatient care s

Ambulatory surgical center s

(ASC) care

Mental health services 8

Coverage limited to 90 days per spell of illness,a

plus 60-day “lifetime

reserve. “

Coverage begins after patient pays .$592 deductible (per spell of illness). No coinsurance for days 1 through 60. Patient must pay coinsurance equal

to 25% of deductible for days 61 through 90.

Patient pays coinsurance equal to 50% of deductible for each of the 60

“lifetime reserve” days. After lifetime reserve is used up, patient is

responsible for 100% of the hospital bill.

Same as acute inpatient but limited to 190 total days of coverage.

Limited to 100 days of care per spell of illness.

Patient must pay coinsurance equal to 1/8 of hospital deductible after day

20 ($74 in 1990).Does not cover custodial-only care in a nursing facility.

Patient must have been hospitalized for at least 3 consecutive days within

past 30 days for benefit to apply.

Patient must be homebound and in need of only part-time or intermittent

nursing (no limit on other visits).

Does not cover custodial services (e.g., housekeeping, cooking, bathing).

Services must be furnished under a physician’s plan of care.

No coinsurance or deductible for most home health services; 20%

coinsurance on new durable medical equipment.

Limited to 210 days of hospice care for terminally ill patients.

Patient must pay coinsurance equal to 5% of drug costs or $5, whichever isless.

Patient must also pay coinsurance equal to 5% of Medicare’s cost for daily

respite care services, up to a limit equal to the hospital inpatient

deductible.

Patient must give up the right to most other Medicare benefits to receive

hospice services (this election is revocable).

Patient pays 20% coinsurance on allowed charges after initial annual part

B deductible (deductible is $75 in 1990).

Patient pays any part of bill that exceeds allowed charge if physician

does not accept assignment (up to a maximum).

Benefit includes only diagnostic and treatment services; most preventiveservices not covered.

c

Patient pays 20% coinsurance on charges after meeting part B deductible.

Patient pays 20% coinsurance on applicable ASC payment amount after

meeting part B deductible.

Subject to $250 annual Medicare payment limit.

‘A “spell of illness” begins with the first day of hospitalization and ends when the beneficiary has not been

an inpatient in a hospital or skilled nursing facility for 60 consecutive days.

bHome health services are covered under both parts A and B.cExcepkions are vaccine for pneumococcal pneumonia, vaccine for hepatitis B for high–risk individuals, routine

Pap smears (as of July 1990), and preventive services provided to Medicare beneficiaries enrolled in healthmaintenance organizations.

SOURCE: Office of Technology Assessment, 1990. Information from Comnerce Clearing House, Inc., Medicare and

Medicaid Guide (Chicago, IL: Comnerce Clearinghouse, Inc., 1990).

the DRG weight. The DRG weight depends only on Additional payments are also made to certainthe diagnosis of the patient. The standardized hospitals for other costs specific to the type of

amount and the wage index, however, distinguish hospital and the population it serves. These include:

among hospitals on the basis of whether or not the q payments to account for the indirect costs to ahospital is located in a metropolitan statistical area hospital of providing medical education to(see box 3-A). physicians,


Box 3-A—Summary of Formula for Medicare Payment to Hospitals for Inpatient Care, January 1990

(1) (2) (3)Total payments = total diagnosis-related group (DRG) payments+ additional payments+ pass-through payments



(a) (b) (c)(1) Total DRG Payments= regular DRG payments + payments for transfers + outlier payments

(a) Regular DRG payment= standardized amount X wage index X DRG weightq The standardized amount varies by location, with the difference between nonmetro and “all other”

metro areas scheduled to be gradually phased out. In 1989 these basic amounts were:

$3,396.56 in metro areas of over 1 million population;

$3,342. ’79 in all other metro areas; and

$3,107.20 in nonmetro areas.

. The wage index applies only to the labor portion of the standardized amount (the labor portion is 74.4

percent of that amount). The 324 metro areas each have a unique wage index. There are also 48

nonmetro wage indexes, one for all the nonmetro counties in each State (Rhode Island and New Jersey

have only metro areas).

. The DRG weight depends on the diagnosis of the patient. There are 474 separate weights.

@J Payments for transfers:

qHospitals receive a per diem payment for each day before a patient is transferred (up to the DRGpayment).

qPer diem rate = regular DRG rate ÷ the national average length of stay for that DRG.(c) Outlier payments:

. Payments are the greater of day or cost payment.

. Day payments are 60 percent of the per diem rate for that DRG for each day above a set day outlierthreshold.

. Cost outliers payments are 75 percent of excess cost of case over set cost outlier threshold for that DRGin that hospital.

c Outlier payments are financed with a Federal set-aside of 5 to 6 percent of total DRG payments.qPayments are financed from separate pools for metro and nonmetro hospitals.

(2) Additional payments go only to qualifying hospitals.q

q

q

The teaching adjustment g&s to teaching hospitals to compensate for the indirect costs of medical

education. The payment is the total DRG payment times an adjustment factor; the adjustment factorequals approximately 7.7 percent for each 10 percent increase in the hospitals intern-and-resident-to-bed ratio.The disproportionate share adjustment goes to hospitals serving high numbers of low-income

patients. The factor for this adjustment is based not only on the proportion of low-income patients but

also on a formula that differs depending on a hospital’s location and size. Adjustment factors for small

hospitals at-e generally lower than those for large hospitals.

The ESRD additional payment goes to hospitals serving end-stage renal disease patients withunrelated illnesses. The payment is a fixed amount per patient per week ($335) for inpatient dialysisservices.

(3) Pass-through payments go to all hospitals incurring relevant costs.Capital costs (for rent, interest, depreciation) are paid at 85 percent of Medicare’s share of actual costs.Direct costs of medical education programs (e.g., for residents’ salaries) are reimbursed at a paymentrate that equals a hospital-specific fixed amount per full-time equivalent (FTE) resident, times thecurrent number of FTE residents, times Medicare’s share of inpatient days.Direct costs of other hospital-based education programs are reimbursed for reasonable costsactually incurred.Other pass-through payments are made for reasonable organ procurement costs and for bad debts of Medicare beneficiaries.

SOURCE: Adapted from Prospective Payment Assessment Commissio~ Washingto~ DC, “Hospital Payment Under PPS During FY 1990,”unpublished briefing document, 1989.

Chapter 3-Federal Programs Affecting Rural Health Services . 65

. payments to hospitals serving a disproportion-ate share of low-income patients, and

q payments for the costs of serving end-stage

renal disease patients with unrelated illnesses.

Alth h f l h it l t hi h i

sole source of local inpatient hospital care becauseof their isolated location, weather conditions, travelconditions, or the absence of other hospitals (see box3-B). Because the closure of these hospitals would

leave their Medicare patients without a local source



Although a few rural hospitals are teaching hospi-tals, and some are eligible for the disproportionateshare payments, urban hospitals are more likely thanrural ones to provide these services and to qualify forthe additional payments or adjustments (491).

Finally, hospitals are reimbursed for capital andother “pass-through’ expenses that are not affectedby the DRG rate. In the initial years of PPS, hospitals

were reimbursed at cost for the Medicare share of their capital expenses, but in the past few yearshospitals have not been able to recoup fully theseexpenses due to congressionally mandated limits onMedicare payment. In 1990, capital is reimbursed at85 percent of Medicare’s share of the cost (140).

Payments to Special Categories of Hospitals—Four categories of rural hospitals qualify for special

consideration under PPS: rural referral centers, solecommunity hospitals, Essential Access CommunityHospitals, and Rural Primary Care Hospitals.

Rural referral centers (RRCs) are usually large,tertiary-care rural hospitals that serve a wide geo-graphic area. To qualify for the designation, hospi-tals must meet certain size and referral characteris-tics (see box 3-B). RRCs are assumed to have costprofiles more similar to urban facilities than to other

rural hospitals. Thus, their DRG payments are basedon the standardized amount applicable to metropoli-tan areas of fewer than 1 million residents, ratherthan being based on the lower rural standardizedamount.

The initial legislation stipulated that RRCs mustbe recertified every 3 years to continue to qualify forhigher payments. Subsequent legislation (Public

Law 99-509, Public Law 101-239) made qualifica-tion automatic for all current RRCs until October 1,1992. As of April 1990, 245 rural hospitals weredesignated RRCs (448).

Sole community hospitals (SCHs) represent theother end of the rural hospital spectrum. These arehospitals, usually small, that are presumed to be the

leave their Medicare patients without a local sourceof care, they qualify for special consideration.

Effective April 1, 1990 (Public Law 101-239),hospitals that are designated SCHs receive MedicarePPS payments that are the highest of:

. the full Federal PPS rate,

. 100 percent of a target amount based on thehospital’s 1982 costs, or

. 100 percent of a target amount based on thehospital’s 1987 costs.

3

An additional payment maybe provided if the SCHexperiences a decrease of more than 5 percent in itstotal inpatient discharges due to circumstancesbeyond its control. Unlike other hospitals, SCHs arereimbursed for 100 percent of Medicare-relatedcapital costs.

As of April 1990, 375 hospitals were designatedSCHs (448). Some hospitals that could qualify forthis designation have not sought it because until thenew SCH payment options were passed in late 1989,their payments were higher under the usual PPS rates(488). These eligible but undesignated hospitals arenow also eligible to receive payment under SCHrules, as are small (fewer than 100 beds) ruralhospitals for whom Medicare patients make up 60

percent of the total caseload4

(Public Law 101-239). Essential Access Community Hospitals (EACHs)

and Rural Primary Care Hospitals (RPCHs) are newdesignations, introduced in 1989 (Public Law 101-239). RPCHs will be small facilities providingemergency and very limited inpatient care that willinitially receive cost-based reimbursement. (Analternative payment system specific to these facili-ties is to be developed.) EACHs are envisioned aslarger facilities that provide backup to primary carehospitals; designated facilities will automaticallyqualify for SCH payment rules (as described above)(Public Law 101-239). EACH and RPCH designa-tions will be limited to hospitals in only a few States(see ch. 8). No designations had been made as of April 1990.

gfior t. April 1990, SCHS w e r e paid on a prorated basis in which only 25 percent of the per-case payment was based on regional DRG rates; tie

remaining 75 pement was based on the hospital’s actual costs.

4Srn~l IIMrd hospi~s in which Medicare patient days are 60 percent or more of total patient days also qualify, even if tieti achud proportion of

Medicare patients is less than 60 percent (Public Law 101-239).


Box 3-B-Qualifying Criteria for Rural Referral Centers and Sole Community Hospitals

A hospital qualifies as a rural referral center if it is located in a nonmetro area and meets any one of thefollowing three specifications (42 CFR 412.96).

1 It has 275 or more beds



1. It has 275 or more beds.2. It has:

a. at least 50 percent of its Medicare patients referred from other hospitals or from physicians not on thehospital’s staff,

b. at least 60 percent of its Medicare patients residing more than 25 miles from the hospital, andc. at least 60 percent of the services it furnishes to Medicare beneficiaries furnished to those who live more

than 25 miles from the hospital.3. It has:

a. annual inpatient discharges equal to at least:

—5,000 discharges (for nonosteopathic hospitals),—3,000 discharges (for osteopathic hospitals), or-the median number of discharges for urban hospitals located in the same region;b. a case mix index

1--a measure of the medical complexity of patients treated-equal to at least:

—the national median case mix index for all urban hospitals, or-the median case mix for urban hospitals located in the same region, excluding hospitals with approved

teaching programs; andc. it meets at least one of the following three criteria:—more than 50 percent of the hospital’s medical staff are specialists,—at least 60 percent of discharged inpatients reside more than 25 miles from the hospital, or

—at least 40 percent of inpatients have been referred either from physicians not on the hospital’s staff orfrom other hospitals.To qualify as a sole community hospital (SCH), a hospital must meet one of the following four sets of

specifications (42 CFR 412.92).

1. The hospital is more than 35 miles from other similar hospitals.2

2. The hospital is between 25 and 35 miles from other similar hospitals, and meets one of the followingconditions:a. no more than 25 percent of the total residents or Medicare beneficiaries in the hospital’s service area are

admitted to other similar hospitals;b. the hospital has fewer than 50 beds but (because it does not provide certain specialty services and

consequently beneficiaries must seek care outside the area for these services) is unable to meet the “25percent” criterion above; or

c. other similar hospitals are inaccessible for at least 1 month of each year because of local topography orsevere weather conditions.

3. The hospital is between 15 and 25 miles of other similar hospitals, but it is inaccessible for at least 1 monthof each year because of local topography or severe weather conditions.

4. The hospital was a Medicare-designated SCH at the time that PPS was implemented. (Because of this“grandfather” clause, many hospitals currently designated as SCHs do not meet any of the first threecriteria (739).)

l~e cu e m ix i ndex is a m-we of the costliness of the cases (patients) treated by a particular hospital r elative tO the COSt of the mtio~average of all Medicare hospital cases.

%ongress in 1989 (Public Law 101-239) modi.fkd the eligibility requirements for SCHS to reduce the number of miles an SCH must behorn another hospital from 50 to 35 miles. (The Secretary of the Department of Health and Human Services (DHHS) may designate SCHS thatare less than 35 miles from another hospital according to criteria to be developed by DHHS.) In additioIL under this law, the Secretary of DHHSmust develop and promulgate new distance criteria based on travel time.


Payment for Outpatient Care

Payment to Ambulatory Surgical Centers—Anambulatory surgical center (ASC) operates exclu-

sively for the purpose of providing surgical servicesto patients not requiring hospitalization To receive

Four major factors may lead to urban/rural Medi-care physician payment differences:

1. Physician specialty distribution—Historically,

for any given service, general and familypractitioners have had lower charges and



sively for the purpose of providing surgical servicesto patients not requiring hospitalization. To receiveMedicare payments, an ASC must be certified by theprogram, and the services for which it bills Medicinemust be approved for provision in that setting. ASCservices are reimbursed according to a fee schedulethat categorizes each approved procedure into one of six rate categories, depending on the complexity of the service (53 FR 31468). Only about 15 percent of

ASCs are in rural areas (99), probably because suchfacilities rely on high service volumes.

Hospital Outpatient Payment—Unlike ASCs,

hospitals are not limited to any specific set of procedures or services that can be provided tooutpatients.

5Nonsurgical hospital outpatient serv-

ices (and some surgical ones) are reimbursed at thelesser of either actual charges for the service or thehospital’s reasonable costs of providing the service

(as reported to Medicare on the hospital’s annualcost reports). Payment for most outpatient surgicalservices (i.e., those that can also be performed byASCs) is based on the lesser of two amounts:

1. reasonable costs or charges, whichever islower; or

2. a 50/50 percent blend of the above rate and theASC rate for that service (490).

Payment to Physicians

Physicians are reimbursed for covered services

rendered to Medicare beneficiaries on a fee-for-

service basis. At present, Medicare’s ‘‘approved

charge” for a service is set at the lowest of:

qthe actual billed charge;

. the physician’s customary charge for the serv-

ice, based on that physician’s prior billings tothe Medicare carrier; or

qthe prevailing charge for that service, based on

comparable physicians’ prior billing for the

same service in that region (615).6

2.

3.

4.

for any given service, general and familypractitioners have had lower charges andreceived lower Medicare reimbursements thanpractitioners in other specialties (475). Sincethese types of physicians are disproportion-ately located in rural areas (see ch. 10), ruralphysicians’ average charges and reimburs-ments are correspondingly lower than those of urban physicians.

Type of physician services-Historically, surgi-cal services have yielded higher charges andpayments than counseling and other consulta-tive services (475). Since most physicians whoperform specialized surgical services are lo-cated in urban areas (see ch. 10), averagephysician charges and payments may be corre-spondingly lower in rural than in urban areas.

Patients’ ability to pay-Rural residents have

lower average incomes than urban residents(see ch. 2). To the extent that rural physicianscharge their patients correspondingly less thanurban physicians do, these lower charges arereflected in lower ‘customary and prevailing’charges and lower Medicare reimbursements.

Physician location in understaffed areas—

Physicians practicing in federally designated“high priority" rural Health Manpower Short-

age Areas (HMSAs) are paid an additional 5percent above the approved charge for eachservice reimbursed by Medicare (Public Law100-203). As of January 1991, the bonus willincrease to 10 percent and will apply to allrural HMSAs (Public Law 101-239) (see ch.13).

Beginning in 1992, Medicare will gradually

switch from the current “reasonable charge” pay-ment system to a fee schedule, in which payment fora service is based on a national rate (which is thenadjusted according to geographic location). Underthe new system, the payment will be the lesser of the

sIt is possible for ahospiti to have its outpatient department cert.ifled as an ASC (47 FR 34082), but because of tie more rigid Payment me~od an drestrictions on procedures that can be performed under ASC rules, it is probable that few hospitals have done so.

6rfa p@icim ~*&5 t. accqt ~~~si~ent’ ‘—i.e., accept reimbursement from Medicare as payment in full-he or she cannot bf l l t ie beneficiary

fo r any amount over the 20 pe~ent coinsurance and any remaining deductible. If the physician does not accept assignment, his or her expected fullpayment is not bound by the arno~t of the approved charge, and the beneficiary is liable for any difference between the physician’s actual charge andthe allowed charge (up to a maximum), in addition to the coinsurance and deductible. Physicians may decide whether to accept assignment on acase-by-case basis. Alternatively, a physician carl elect to be a ‘‘participating physician’ by agreeing to accept assignment on all Medicare claims forthe next 12 months.


actual charge or the fee schedule amount. Once thenew system is fully implemented, payment amountswill not depend on the specialty of the physicianconcerned (Public Law 101-239). Ii-ban/rural dif-

ferences in Medicare payments to physicians for ai i ill till i t h f th

families with dependent children, or first-time preg-nant women. These individuals generally becomeeligible for Medicaid through enrollment in anotherpublic assistance program.

7For example, all persons

receiving payments under the Aid to Families withD d t Child (AFDC) t ti



p y p ygiven service will still exist, however, for threereasons. First, the new payment system includes anexplicit geographic adjustment factor, under whichservices provided in an area with low physicianpractice costs will be paid at a lower rate thanservices in higher-cost areas (Public Law 101-239).Second, to the extent that rural physicians chargeless than urban physicians and less than the fee

schedule amounts, payments will also be less. Third,the HMSA bonus will continue to apply under thenew system.

Medicaid

Medicaid is a federally aided, State-administeredprogram that provides medical assistance to anestimated 24 million low-income people (146).Operating within Federal guidelines, each State

designs and administers its own Medicaid program.Thus, although the Federal Government sets someminimum standards, Medicaid eligibility require-ments, services offered, and methods and levels of payment to providers vary widely among the States.The Federal Government pays 50 to 80 percent of each State’s Medicaid expenditures, based on State-specific matching formulas (which are related toState per capita income) (199). Total Medicaid

outlays in 1990 are projected to be approximately$71 billion, of which the Federal share will be $40

billion (199).

Medicaid policies can have different effects on

urban and rural residents resulting from three

factors: eligibility criteria, reimbursement methods,

and physician participation differences. There is no

direct way to measure urban/rural differences in

Medicaid status based on published data; virtuallyall data on Medicaid are State-based.

Eligibility

Individuals are ‘categorically eligible’ for Medi-

caid if they have low incomes and fall into one of

five categories: aged, blind, disabled, members of

g p yDependent Children program (AFDC) are automati-cally eligible for Medicaid. In addition, Medicaideligibility in most States is extended to all aged,blind, and disabled individuals (including children)who receive cash assistance under the FederalSupplemental Security Income (SSI) program. (Tobe eligible for SSI, an individual must be disabledand must have available income and resources no

higher than established limits.) Fourteen States,however, exercise the so-called “209(b)’ option bylinking Medicaid eligibility for SSI beneficiaries toState standards that are more restrictive than Federalstandards (610).

8

Congress has been expanding Medicaid eligibilitysince 1984 to include many individuals-particularlypregnant women and infants-who would not other-wise meet income and categorical standards. As of July 1990, all States are required to extend Medicaideligibility to pregnant women and young childrenwhose family incomes are within 133 percent of theFederal poverty level (Public Law 100-360). Inaddition, 14 States have chosen the option, intro-duced in 1987 (Public Law 100-239), to makeeligible pregnant women and infants with incomesup to 185 percent of the Federal poverty level (table3-3) (26O,418,61O).

Eligibility for Medicaid varies a great deal amongthe States, particularly for individuals whose Medi-caid eligibility is based on their eligibility forAFDC. In 1989, the State AFDC income eligibilitylevels for a family of three ranged from 14 to 77percent of the Federal poverty level (table 3-3) (260).Thus, with the exception of pregnant women andinfants, individuals in different States who are

equally poor can differ enormously in their Medicaideligibility.

Until October 1990, when new Federal require-ments go into effect, family structure also affectsMedicaid eligibility. Poor two-parent families can-not qualify for AFDC in many States, and thus in the

7stite~ ~ve the option t. de .sOme other ~oups ~qon~ly eligible ~ we~ (e.g., individ~s who are eligible for public assistance but notreceiving iq some individuals who lose public assistance eligibility due to increased income, and disabled children who would be eligible for assistanceif institutionalized.)

8~ e ~~z@@)~~ oPtion pe~ts s~tes t. rem the more res~ctive level of benefit eligibili~ that efisted k &ese States prior to the Federal

implementation of the SS 1 program.


Table 3-3-Some Basic Eligibility Characteristics of State Medicaid Programs

Coverage for pregnant

AFDC-related income SSI-related women and infants (1990)

eligibility cutoff eligibility Covers Income

level (Per month) (1989) more Has families eligibility Age

i i i i h 2 ff



In As percent restrictive medically with 2 level as cutoff

dollars of Federal than Federal needy unemployed percent of for

(family poverty requirements program parents Federal covered

State of 3) level (1988) (1989) (1989)a

poverty levelb

infants

Alabama. . .............118 14 100 1

Alaska. . ..............809 77 100 3

Arizona. . .............293 35 100 3

Arkansas. . . . . . . . . . ....204 24 x 100 6

California. . ..........663 79 x 185 1

Colorado. . ............421 50 75 1

Connecticut. . .........534 64 x x 185 6

Delaware. . . . . . . . . . . . . .333 40 100 3

District of Columbia. .393 47 x 100 3

Florida. . .............287 34 x x 150 6--------------------------------------------------------------------------------------------------------------Georgia. . .............376 45 x 100 4

Hawaii. . . . . . . . . . . .. ...557 58 x x x 185 7

Idaho. . ...............304 36 75 1Illinois. . ............342 41 x x 100 1

Indiana. . . . . . . . . . . . . . .288 34 x 100 3Iowa. . ................394 47 x 185 6Kansas. . ..............401 48 x 150 5

Kentucky. . ............218 26 x x 125 2Louisiana. . . . . . . . . . . ..190 23 x 100 6Maine. . ...............632 75 x 185 5--------------------------------------------------------------------------------------------------------------

Maryland. . ............377 45 x 185 2

Massachusetts. . .......579 69 x 185 5Michigan. . ............572 68 x 185 3

Minnesota. . . ..........532 64 x x x 185 5

Mississippi. . .........368 44 185 5

Missouri. . ............285 34 x 100 3

Montana. . .............359 43 x 100 1

Nebraska. . ............364 43 x x 100 3

Nevada. . ..............330 39 75 7New Hampshire. . .......496 59 x x 75 1--------------------------------------------------------------------------------------------------------------

New Jersey. ., . . . . . . . . .424 51 x x 100 5New Mexico. . . . . . . . . . . .264 32 100 4

New York. . ............539 64 x x 185 1North Carolina. . .. ....266 32 x x 150 6North Dakota. . ........386 46 x x 75 1Ohio. . ................321 38 x 100 2Oklahoma. . ............471 56 x x 100 2Oregon. . ..............412 49 x 85 4

Pennsylvania. . . . . .. ...384 46 x x 100 3

Rhode Island. . . .......517 62 x x 185 6------------------------------------------------------------------------------------------ -----—--—---— -------

( c on t inuedonnex t page )

past they have not been able to qualify for Medicaid would be categorically eligible for Medicaid except(table 3-3) (610). Since poor two-parent families are that their income and resources are too high, and 2)disproportionately located in rural areas (see ch. 2), have high medical expenses. In the 35 States (and thepoor rural residents have been less likely than poor District of Columbia) that have medically needyurban residents to be Medicaid-eligible. programs, these individuals become eligible for

Medicaid once they have spent enough on medical

States have the option to offer Medicaid to care to reduce their net resources to State-established“medically needy” individuals-those who: 1) limits. Each State may designate its own medically


Table 3-3-Some Basic Eligibility Characteristics of State Medicaid Programs-Continued

Coverage for pregnant

AFDC-related income SSI-related women and infants (1990)

eligibility cutoff eligibility Covers Income

level ( Per month) (1989) more Has families eligibility Age





dollars of Federal than Federal needy unemployed percent of for

(family poverty requirements program parents Federal covered

State of 3) level (1988) (1989) (1989)a

poverty levelb

infants

South Carolina. . ......403

South Dakota. . ........366

Tennessee. . ...........365

Texas. . ...............184

Utah. . . . . . . . . . ........502

Vermont. . .............629

Virginia. . ............291

Washington. . ..........492

West Virginia. . .......249

Wisconsin. . . . . . . . . ....517

Wyoming . . . . . . . . . . . . . ..360

48

44

44

22

60

75

35

59

30

62

43

x

x

xxxx

xx

xx

185

100

100

130

100

185

100

185

150

x 82d

100

62

6426

27

711

ABBREVIATIONS: AFDC = Aid to Families With Dependent Children.

aAs of October 1990, all States Will be required to make eligible for AFDC (and Medicaid) all families ‘ho

would be eligible for AFDC under current rules except that the principle wage-earner is unemployed (Public

Law 100-485).b

As of April 1990, all States must make eligible for Medicaid all pregnant women and infants up to age 1 whose

incomes are no more than 133 percent of the Federal poverty level (Public Law 101-290). All children bornafter September 1990 whose family incomes are within this amount must also be made eligible through the age

of 6. (Although this new standard is a Federal mandate, in fact it may take some time for many States to

actually come into compliance with the new law. )

SOURCES: I. Hill, National Governor’s Association, Washington, DC, unpublished memorandum, May 11, 1989; U.S.Congress, Congressional Research Service, Medicaid Source Book: Background Data and Analysis,

House of Representatives Committee Print No. 1OO-AA (Washington, DC: U.S. Government Printing Of-fice, November 1988).

needy income and resource standards, but thesestandards cannot exceed 133 percent of the State’s

AFDC income and resource standards (610). Thus,even in the States that offer medically needyprograms, Medicaid eligibility under these programsvaries with AFDC standards.

Covered Services

As a condition of matching funding, the Federal

Government requires State Medicaid programs to

cover certain basic inpatient, outpatient, and long-term care services for their categorically eligible

populations (table 3-4). States also have the option

to cover additional services.

In general, any services covered under the pro-

gram must be made available to all Medicaid

recipients, but several major exceptions to this rule

exist. First, States with medically needy programs

may provide more limited coverage for these indi-

viduals than for categorically eligible individuals,

although in fact almost none do so (475). Second,under apart of Medicaid known as the Early and

Periodic Screening, Diagnosis, and Treatment (EPSDT)program, children can receive a broad range of screening and followup services not available toother Medicaid beneficiaries. And third, States insome cases may obtain waivers to the usual rules,enabling them to offer certain services to a specifiedpopulation (e.g., the elderly). Under one Medicaidwaiver program, for instance, States may provide awide range of community-based services necessaryto keep people who would otherwise reinstitution-alized in their homes.

Compared with Medicare, Medicaid offers amuch broader range of services, but it also placesmuch stricter limits on their use. Some importanttypes of limits

9are:

q Mechanisms to control the use of hospitals—

Particularly important are limits on the length

9Someof~e~e~t=.gV ~n~u~towc~evisits tophysici~s~o notapply to c~drenreceivin gservices under theEPSDTprogram.

Chapter 3--Federal Programs Affecting Rural Health Services . 71

Table 3-4-Services Covered Under Medicaid

Mandatory servicessInpatient hospital services

sOutpatient hospital services

sPhysician servicesqEarly and Periodic Screening, Diagnosis, and

q Restrictions on physician visits—As of 1986,44 States and the District of Columbia limitedthe annual number of physician visits coveredby Medicaid (653). Six States limit the number

of reimbursable office visits (limits range from12 to 48 visits a year); 3 States limit the number



Treatment (EPSDT) for childrena

sFamily planning services and supplies

sLaboratory and X-ray procedures

m Adult skilled nursing facility care

sHome health care services for adults

sRural health clinic services

sServices of certified nurse-midwives

Optional servicess

s

s

s

s

q

s

s

s

s

s

s

s

s

Additional home health services

Additional dental services

Services of chiropractors, optometrists,

podiatrists, and other licensed practitioners

Clinic services

Other diagnostic, screening, preventive, and

rehabilitative services

Drugs

Intermediate care facility services

Eyeglasses, prosthetic devices, and orthopedic

shoes

Home and skilled nursing facility care for

children

Private duty nursing

Inpatient psychiatric care for children

Physical, occupational, and speech therapies

Inpatient services to elderly persons in men-

tal disease or tuberculosis facilities

Other medical or remedial care recognized un-

der State law, including transportation and

emergency services

aEpSDT is a program Within Medicaid that combines

outreach, health screening, followup care for

detected conditions, and case management. Each

State is required to offer EPSDT services to allMedicaid-eligible children and youth under 21.


vices, Health Care Financing Administra-

tion, Medicare and Medicaid Data Book, 1988

(Baltimore, MD: U.S. DHHS, April 1989).

of hospital stay and total number of days of carecovered annually. In 1986, 11 States limited thenumber of days of hospital care for which they

would pay (653). Restrictions ranged fromlimits of 12 to 60 days a year and 14 to 30 daysfor each admission or spell of illness. Inaddition, 12 States restrict the ability of patientsto readmitted to the hospital on weekends oron days preceding the day an operation isscheduled. Ten States limit the number of hospital outpatient visits a year that will bereimbursed.

yof home physician visits; 1 State limits the

number of emergency room visits per year; and6 other States limit the total number of physi-cian visits provided for other than hospitalinpatient care, with limits ranging from 12 to 24visits per year. In addition, 10 States limitphysician visits in the hospital, and 11 limit

visits in long-term care facilities (653).q Prior authorization and second opinion re-

striations—Many States require recipients toreceive permission from Medicaid before re-ceiving certain services--e.g., elective surgery,care provided in certain settings, or psychiatricservices. Statesman also require the opinion of a second physician before a patient may un-dergo certain procedures (653).

Many other limits on specific services exist aswell. Some States limit the number of particularservices provided (e.g.psychiatric visits, eye exams).States also impose limits on institutional and home-based long-term care services, therapy services,home medical equipment, and the number and typesof prescription drugs that me covered (653).

Reimbursement

Hospital Care—Most States now pay for hospitalcare based on some kind of prospectively set rate perday, per discharge, or per admission (table 3-5).States use a wide variety of methods to set theserates, including selective contracting, hospital-specific negotiated rates, DRG-based methods, andpast hospital costs (610). Only three States (Dela-ware, West Virginia, and Wyoming) base their

Medicaid payment for inpatient care to a patient onthat patient’s actual incurred costs; one additionalState (Utah) does so only for rural hospitals (343a).

Medicaid payment methods for hospital outpa-tient services are even morevaried, ranging from feeschedules and other forms of prospective rates topayments based on either costs or charges.

10Only

Delaware and Wyoming pay for both inpatient andoutpatient services based on hospitals’ actual costs.

loAs usedhere, “costs’’referto actual costs oftreating patients (e.g. staffsakaies, supplies, depreciation). “Charges’’a rethepricest hat hospitals

assigntosenices when billing patients orpayers. Charges are not necessarily directly related to costs.


Table 3-5-State Medicaid Hospital and Physician Reimbursement Methods, Fiscal Year 1987

S t a t ea Hospital inpatient Hospital outpatient Physicians’ services

Alabama

Alaska

ArkansasCalifornia

Colorado

Prospective rate

Prospective rate

Prospective rateProspective rate

Prospective rated

Fee schedule

Prospective rate

Fee scheduleFee schedule

b

Percent of costsc

Prevailing charges

Prevailing charges

Fee scheduleRelative value scale

Relative value scale



Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

IowaKansas

Kentucky

Louisiana

Maine Maryland

Massachusetts

Michigan Minnesota Mississippi Missouri Montana

Nebraska Nevada New Hampshire New Jersey

New Mexico New York

North Carolina North DakotaOhioOklahoma

OregonPennsylvania

Rhode IslandSouth Carolina

South Dakota

TennesseeTexasUtah

Vermont

Virginia Washington

West Virginia Wisconsin

Wyoming

Prospective rate

Prospective rate

Cost-based rate

Prospective ratee

Prospective rate

Prospective rate

Prospective rate

Prospective ratee

Prospective rate

Prospective ratee

Prospective rated

Prospective rated

Prospective rate

Prospective rate

Prospective rate

Prospective rate

Prospective rate

Prospective rated

Prospective rated

Prospective rate

Prospective rate

Prospective rated


Prospective ratede

Prospective rated

Prospective rate

Prospective rate

Prospective rate

Prospective ratede

Prospective rated

Prospective rate

Prospective rated

Prospective rated


d

Prospective rated


d

Prospective ratedf

Prospective rate


d

Cost-based rateProspective rate

Cost-based rate

Percent of costs

Prospective rate

Reasonable costs

Prospective rate

Prospective rateCost-to-charge ratio

Negotiated rateReasonable costs

Fee scheduleReasonable costs

Reasonable costsFee schedule

Percent of chargesReasonable costs

Reasonable costsProspective rate

Prospective ratePrevailing costsPrevailing charges

Reasonable costsPercent of costs

c

Reasonable costs

Prevailing chargesFee scheduleReasonable costsCost-to-charge ratio

Reasonable costsFee schedule

Percent of costReasonable costs

Reasonable costsPercent of inpatient ratePercent of cost

Fee scheduleProspective rate

Percent of cost

Reasonable costsReasonable costsReasonable costsPercent of chargesReasonable costsReasonable costsProspective rate

Fee scheduleProspective rate

Reasonable costs

Relative value scale

Fee scheduleFee scheduleFee scheduleFee scheduleFee schedule

Prevailing chargesRelative value scale

Fee schedulePrevailing charges

Prevailing chargesPrevailing charges

Prevailing chargesPrevailing chargesFee scheduleFee schedule

Fee scheduleFee schedulePrevailing chargesFee scheduleFee scheduleFee schedule

Prevailing chargesFee scheduleFee scheduleFee schedule

Prevailing chargesFee schedule


Fee schedulePrevailing charges

Fee scheduleFee schedule

Fee scheduleRelative value scale

Prevailing charges


Fee scheduleFee scheduleFee scheduleFee scheduleFee schedulePrevailing charges

Prevailing charges

aArizona does not operate a fully fledged Medicaid Program; its more limited medical assistance program oper-

ates as a demonstration program under waivers of certain Medicaid requirements.bor negotiated rates.C

orp e r c e n t o f charges.

dRates are weighted by diagnosis-related grouP.

‘Current as of 1989.fRural hospitals are paid 95 percent of reasonable costs.

SOURCES: J. Leuhrs, National Governor’s Association, Washington, DC, “Sumnary of State Medicaid Inpatient

Hospital Coverage,” memorandum to interested parties, Dec. 18, 1989; and U.S. Congress, Congress-

ional Research Service, Medicaid Source Book: Background Data and Analyses, House of

Representatives Comnittee Print No. 1OO-M (Washington, DC: U.S. Government Printing Office,November 1988).






payment per visit ($47.38 in 1990) (Public Law100-203). For provider-based RHCs, payment byboth Medicare and Medicaid is made according to aMedicare cost-based reimbursement formula with

no ceiling on the reasonable costs (Public Law95-210). In either case, reimbursement is to theclinic that employs the practitioner rather than

The legislation creating the block grant elimi-nated most of the requirements for providing spe-cific services. Fifteen percent of the total fundingcontinued to be set aside for special demonstration

projects, leaving 85 percent of appropriated funds tobe allocated among the States. States were requiredto match every 4 Federal dollars received with 3



clinic that employs the practitioner rather thandirectly to the practitioner.

HEALTH BLOCK GRANT

PROGRAMS

This section briefly describes three Federal block grant programs that affect health services in bothrural and urban areas. All were created by the 1981Omnibus Budget Reconciliation Act (Public Law97-35), which consolidated various sets of categori-cal grant programs into block grants. In each case,the block grant increased State discretion at theexpense of Federal direction and oversight. All threeblock grants have since been amended to coveradditional services. (Individual programs and theirimplications for rural areas are discussed in moredetail in chs. 15 and 16.)

Maternal and Child Health Block Grant

Authorized under Title V of the Social SecurityAct and administered by HRSA, the Maternal andChild Health (MCH) block grant program provides

health services to mothers and children. Instead of operating as an insurance program, the Federalgrants are awarded to the States, which in turn fundpublic and private providers of maternal and childhealth care services (e.g., local health departments).

The MCH block grant consolidated a series of categorical Federal grants for:

q

q

q

q

q

maternal and child health services (including

prenatal care, family planning, well-child care,vision and hearing screening, dental care,immunization, and lead screening);services for disabled and other children withspecial health care needs;Supplemental Security Income services fordisabled children;hemophilia treatment centers; andother programs aimed at specific groups or

health problems (e.g., counseling for parentswhose children were victims of Sudden InfantDeath Syndrome).

to match every 4 Federal dollars received with 3State dollars. An evaluation of the implementationof the block grant program by the General Account-ing Office (GAO) found that States tended to spendtheir allotments in ways similar to prior patterns(612).

In 1986, Congress changed the funding formula toearmark certain funds for specific purposes. Undercurrent law, abase amount ($478 million, an amountequal to the block grant’s fiscal year 1985 appropria-tion) is allocated according to the original formula,with 85 percent distributed to the States and 15percent set aside for demonstration grants (611).Amounts above that base, however, are allocatedunder a new formula. In 1989, 9 percent of theamount above the base was retained by DHHS tofund genetic screening projects. Two-thirds of theremaining amount over the base was allocatedaccording to the 85 percent/15 percent formula. Theremaining one-third was also allocated according tothe formula but was earmarked for programs todevelop primary health services for children andcommunity-based service networks and case man-agement services for children with special healthcare needs (611).

Within the non-earmarked portion of the MCHgrant, States retain tremendous latitude in the use of funds. States determine both the distribution of funds among services and the eligibility criteria forindividuals receiving those services. States maycharge for the services provided. However, they maynot charge mothers and children whose incomes arebelow Federal poverty guidelines, and charges for

those with higher incomes must be based on a slidingscale reflecting income, resources, and family size(611).

Very little is known about who receives what typeof services under the MCH block grant, largelybecause the Federal Government does not requirethe collection or reporting of data on such expendi-tures. This dearth of information is compounded by

the lack of Federal requirements for minimumservices and eligibility. Some self-reported informa-tion from States is available through an annual



Chapter 3--Federal Programs Affecting Rural Health Services . 77

bilitation programs (Public Law 99-570). The 1988Anti-Drug Abuse Act (Public Law 100-690) thenconsolidated the new substance abuse grant into theADMS block grant. (This Act also authorized a

mental health services demonstration program, underwhich 15 percent of appropriated funds for theprogram must be spent on projects in rural areas.)

salaried employees of the Federal Government andpractice where they are sent by the Corps. TheNHSC also includes a much larger group of healthprofessionals who are placed in HMSAs by the

NHSC but who are not actually commissionedmembers.



p g p p j )

Under the present block grant, about two-thirds of the overall Federal appropriation will be allocatedfor substance abuse programs and one-third formental health service activities, although the propor-tions allotted to individual States may differ. Thecurrent formula for distributing funds to the States is

based on each State’s population of age groups atgreatest risk for substance abuse and mental illnessand on total taxable resources of each State. Theformula gives weight to States with urban, youngadult populations, who are presumed to be atespecially high risk of substance abuse (Public Law100-690).

The 1988 Act required each State to use at least 10

percent of its block g-rant allocation for substanceabuse programs, services, and demonstration proj-ects for women, particularly those who are pregnantor who have dependent children. At least 55 percentof the mental health allotment must be used for newcommunity mental health services not availablebefore fiscal year 1988.

In fiscal year 1989, the appropriation for theADMS block grant was $805.6 million, of which 5percent were reserved for data collection and serv-ices research. The remainder was allocated amongthe States, with an estimated $247 million allocatedfor mental health services and $529 million forsubstance abuse services (320).

PROGRAMS TO AUGMENTRURAL HEALTH RESOURCES

Health Personnel Programs16

National Health Service Corps

The purpose of the National Health Service Corps(NHSC), established in 1972, is to encourage healthprofessionals to practice in designated HMSAs. TheNHSC includes a small group of commissionedofficers of the Public Health Service, who are

Originally limited to physicians, the NHSC place-ment program was expanded to include a broadrange of other health professionals as well, includingmidlevel practitioners (462). The majority of NHSCplacements, however, are still physicians.

The placement program has three components:

the Volunteer Program, the Scholarship Program,and the Loan Repayment Program. The VolunteerProgram consists of health professionals who arerecruited by the NHSC to serve in HMSAs but whoare under no legal obligation to do so. Thesevolunteers may either establish private practices orreceive their salary from a variety of public andprivate employers. They are not counted as NHSCfield personnel.

17

Under the Scholarship Program, individuals en-tering medical (or other health professional) schoolsare awarded scholarships for their health professionseducation. In exchange for each year of scholarshipreceived, the recipient is obligated to practice for 1year in a designated high-priority HMSA (689). Theminimum service obligation is 2 years (662). Since1987, NHSC scholarships have been awarded only

to a few students with extreme financial need (43 in1989) (659).

The Federal NHSC Loan Repayment Program,enacted in December 1987 (Public Law 100-177),pays participants up to $20,000 a year toward theiroutstanding health profession educational loans. Aswith the Scholarship Program, participants mustpractice health care in a designated high-priority

HMSA in order to meet the obligations of theprogram. Obligations are from 2 to 4 years, withlonger obligations receiving higher annual pay-ments. Applicants to the program must be in theirlast year of education to be eligible for considera-tion. Priority is given to applicants who are about tograduate as medical doctors, NPs, or CNMs (662). In1989, 112 placements were made through theFederal Loan Repayment Program (659).

16~y of ~eSe Prowu ~e discussed in more detail i-u Ch. 13.

17~e Sme Prog aISo recruits personnel for the Indian Health Serviee.


A separate loan repayment program, administeredthough the NHSC, operates through the States (seech. 13). States need not adhere directly to FederalHMSA guidelines when designating eligible areas to

carry out the service obligation. Funds are limited,however, and in 1989 only seven States receivedfunds under this program.

include allopathic and osteopathic medical schoolsand groups of such institutions (677).

The Federal “seed money” may not exceed 9years for an individual AHEC, and Federal funding

is decreased after the fourth year. Each project mustcontribute at least 25 percent in matching funds fromState or other sources Eighteen projects in 21 States



Until 1979, when the first large group of obligatedNHSC scholarship recipients came out of the‘‘pipeline, ’ most field placements were volunteers.The NHSC field program (which pays for salaries,placement services, etc. for NHSC-placed person-nel) had its highest level of funding in 1983, but

decreases in total field personnel were not seen untilyears after funding was cut back, due to the long“pipeline’ of the Scholarship Program. Fieldstrength peaked in 1986 and has been declining since(659).

The NHSC directly paid the salaries of most fieldplacements (both obligated and volunteer healthprofessionals) until 1979, when it began to rely moreon other employers and self-employment of physi-cians to support placements. In 1988, only 15percent of NHSC field positions were federallysalaried; the remainder received their salaries fromcommunity and migrant health centers, privatepractices, and other organizations.

Area Health Education Centers

The purpose of the Area Health Education Centers

(AHEC) program is to attract and retain primary careprofessionals in shortage areas by linking academichealth sciences centers with clinical sites in under-served urban and rural communities. Under thisprogram, the Federal Government enters into coop-erative agreements with AHECs to establish net-works of health-related institutions (e.g., academicmedical centers, hospitals, clinics, private medicaloffices) to provide educational services to students,

faculty, and practitioners (Public Law 92-157)(677).

The original AHEC program began in 1972 andfunded selected university medical schools under5-year, incremental contracts, in which fundingincreased during the first 3 years and then decreasedas programs became self-supporting (Public Law92-157) (677). In 1981, the funding mechanism waschanged to a cooperative agreement that required asubstantial Federal role in the management of AHEC projects. Eligible recipients of AHEC funds

State or other sources. Eighteen projects in 21 Statescurrently receive funding for planning, develop-ment, or operation (677). Federal AHEC Programawards in 1988 totaled $15.5 million.

Since the program began, 23 AHECs have gradu-ated from Federal funding. These AHECs are stilleligible for separate demonstration funds for “spe-cial initiative projects. ” In fiscal year 1988, $1.7million was awarded to 28 such projects in 10 States(677).

The AHEC educational mission is very broad;specific programs implemented depend on the needs,desires, and resources of the participants. Programshave included clinical training rotations in underserv-ed rural areas, establishing a Hispanic residency

program in family medicine, training health profes-sionals to work with Native Americans from variouscultures, and facilitating health professions educa-tional programs on such diverse subjects as occupa-tional and agricultural health, primary care forSoutheast Asian refugees, and family and spousalabuse (677).

Border Health Education Centers

The Border Health Education Centers program,authorized by the Omnibus Reconciliation Act of 1989 (Public Law 101-239), funds contracts withschools of allopathic and osteopathic medicine tocreate centers that will improve the supply andquality of personnel providing health services alongthe border between the United States and Mexico.Nonborder areas with large new immigrant popula-tions may also receive funds under the program.

Other Health Professions Education andTraining Programs

A number of other Federal programs, authorizedunder titles VII and VIII of the Public Health ServiceAct, provide support to institutions (through grantsand contracts) and to students (through loans, loanguarantees, and scholarships) in the fields of medi-cine, osteopathy, nursing, dentistry, veterinary med-

icine, optometry, podiatry, pharmacy, public health,and graduate programs in health administration.


Health professions education programs--construc-tion grants to schools and loans to students-wereinitiated in 1963 (Public Law 88-129) and 1964(Public Law 88-581), in response to concerns that

the United States faced a critical shortage of healthpersonnel (319). Over the next decade, the programsexpanded, becoming available to a greater number

nature of the interdisciplinary programs that coulddevelop is unknown.

Institutional Assistance Programs—The FederalGovernment provides grants to family medicine,

pediatrics, general internal medicine, and generaldentistry programs to support the planning , develop-ment maintenance and improvement of primary



of schools and students and a broader range of healthprofessionals. Grant programs to encourage specialprojects at health professions schools were alsoadded (319).

In 1976, Congress began to refocus special projectgrants to emphasize training for primary care provid-ers who would serve in underserved areas, and itbegan to replace broad scholarship programs withmore limited scholarship and loan programs. Legis-lation in 1981 repealed all basic grants to healthprofessions schools except schools of public health,and 1985 legislation extended funding authority forexisting programs that address problems associatedwith improving the geographic and specialty distri-bution of professionals (319). Brief descriptions of current Federal health professions education andtraining programs follow.

Student Assistance Programs—The Federal Gov-ernment funds a number of trainee programs inpublic health schools, public administration schools,preventive medicine departments, nursing schools,and hospitals. (These funds reach students throughthe institutions rather than directly.) The govern-

ment also awards scholarships to some first-yearhealth professions students through the ExceptionalFinancial Need Scholarship Program. Authorizationexists for two student loan programs and one loanguarantee program, none of which have receivedappropriations in recent years (319).

18

A new interdisciplinary training program wasauthorized in late 1989 (Public Law 101-239). Its

purpose is to prepare health professionals for prac-tice in rural areas where personnel are in short supplyby training individuals from different health profes-sions (e.g., pharmacists, physicians, and NPs) towork together in a rural setting. The program isexplicitly focused on nonphysician personnel; nomore than 10 percent of funds may be spent ontraining medical students (Public Law 101-239). Nofunds had been awarded as of April 1990, so the

ment, maintenance, and improvement of primarycare undergraduate and graduate programs. Similargeneral support programs exist for physician assis-tant programs, public health schools, and healthadministration schools. Several institutional grantsare also available to support nursing school pro-grams for NPs and nurse-midwives, other advanced

nursing training, and nursing faculty fellowships(319).

Two small institutional programs are targeted tothe health professions education of minority anddisadvantaged students. The Minority EducationProgram provides grants to four health professionsschools for development of model education pro-grams for minority individuals. The Disadvantaged

Assistance Program provides grants and contracts tohealth professions schools and other organizationsto help them identify, recruit, and prepare minorityand disadvantaged students for health professionscareers (319).

Special Projects-Section 788 of the PublicHealth Act authorizes funding for Special EducationInitiatives/Curriculum Development, which includesgrants and contracts to health professions institu-

tions and other organizations for a variety of projects, including projects to provide support serv-ices to health professionals practicing in HMSAs.Special project grants are also available to nursingschools and other organizations to support projectsto enhance nursing skills and knowledge (319).

Primary Care Facilities and Services

Community Health Centers

The Community Health Center (CHC) Program,authorized in section 330 of the Public Health Actand administered by HRSA's Bureau of Health CareDelivery and Assistance, provides grants to establishand to operate CHCs. These centers provide primarycare services to designated medically underservedareas and populations. To receive Federal funding,

18~e ~ee pro-s we the H~th fiofesSiOn5 Smdent ban Program and the Nursing Student Loan prOgranL which provide low-int~est Ioans to

health professions students, and the Health Education AssMance IminProgTanL which provides a Federal guarantee for private-sector, market-rate loans.


CHCs must provide basic primary health services,including:

q

q

q

physician services (and, where feasible, serv-

ices of PAs and NPs);diagnostic laboratory and radiology services;preventive health services (including family

l i t l d ll hild )

systems for pregnant women and infants, enhancingthe provision of primary and supplemental healthservices, and improving access to these services(320).

DHHS also provides some CHCs with supple-mental project grants and contracts to operate clinicst t t bl k l di i l i Th



q

q

q

q

planning, prenatal, and well-child care);emergency medical services;transportation services (as needed);preventive dental care; andwhere appropriate, pharmaceutical services.

In addition, CHCs may, where appropriate, provide

the following supplemental health services:

q

q

q

q

q

q

q

q

q

q

q

q

q

hospital services;home health services;long-term care services;rehabilitative services;mental health services;dental services;vision services;

therapeutic radiology services;allied health services;public health services (including counseling,referral, and followup for social and nonmedi-cal needs that affect health status);ambulatory surgical services;health education services; andservices that promote the use of the aboveservices, such as interpreters in CHCs that

provide services to a large non-English-speaking population.

In 1988, the Federal CHC program supported 526CHCs, of which 319 were in rural areas.

19O n

average, each rural CHC provided nearly 35,000patient visits in that year (see ch. 5) (658).

CHCs are required to seek third-party reimburse-ment (Medicaid, Medicare, private insurance) if

available. They provide services on a sliding feescale based on income and family size; families withincomes below the Federal poverty level receive freecare.

Recent Federal appropriations for CHCs haveincluded supplemental funding for the Govern-ment’s Infant Mortality Initiative.

20Funds from this

initiative are to be spent on expanding health care

to treat black lung disease in coal miners. Theseclinics operate at 58 CHC sites in 14 States andprovide for the analysis, examination, and treatmentof breathing and lung impairments in active andretired coal miners. In fiscal year 1988, the programprovided services to an estimated 47,500 victims of

black lung disease (611).

Migrant Health Centers

Like CHCs, migrant health centers (MHCs) arepart of HRSA's primary care program. The MHCprogram closely parallels the CHC program. Itprovides grants both to establish and to operatecenters, which must provide the same basic primarycare services provided by CHCs. In addition to thesupplemental services that may be provided byCHCs, MHCs may also provide:

q

q

q

environmental health services (e.g., rodentcontrol, field sanitation, sewage treatment);infectious and parasitic disease screening andcontrol; andaccident prevention programs (including pre-vention of excessive pesticide exposure).

The population that can receive MHC services islimited to migratory and seasonal agricultural work-ers and their families. In 1988, there were 118 MHCgrant recipients operating clinics that served over500,000 people (see ch. 2) (181). Many MHCs alsoreceive funds from the CHC program. As withCHCs, MHC services are provided on a fee-for-service basis, with a sliding fee schedule applying to

those without insurance who cannot pay the fullcharge for the services they receive. MHCs mustaccept patients covered by Medicare and Medicaid.

Primary Care Cooperative Agreements

The Public Health Service, under a programinitiated in 1986, enters into primary care coopera-tive agreements (PCCAs) with individual State

19~c f iwa here refer t. tie ~~er of centers re~iv~g ~eder~ g ran t ~ds, no t tie to~ n umb e r of CWC sites. CHCS Inay have mOm than One

clinic site.% 1990, InfantMortality Initiative funds were folded into the total CHC pool for distribution. Previously these funds were awarded separately.




RURAL HEALTH POLICY AND

RESEARCH

A wide variety of Federal organizations with

disparate mandates carry out some rural healthresearch. For instance, HCFA, the ProspectivePayment Assessment Commission, and the Physi-

in December of 1987, that seined as the foundationfor a discussion of a rural health research agenda forthe 1990s .

Funds allocated to AHCPR’s rural health researchactivities were $679,000 in fiscal year 1989 and $2.5million in fiscal year 1990 (463). Activities fundedwith 1989 funds included studies of:



y ycian Payment Review Commission have all under-taken studies of Medicare payment to rural physi-cians and hospitals. Other Federal organizationsfund studies that are epidemiological or clinical innature (e.g., studies of interventions to improveinfant mortality). Some agencies have consolidated

their rural research efforts; the National Institute of Mental Health established an Office of Rural MentalHealth Research in early 1990, whose responsibili-ties will include administration of a Rural MentalHealth Research Centers program (640,641).

Two Federal organizations have recently beenestablished that have an especially strong andexplicit link between rural health care policy and

research. Descriptions of these two organizationsfollow.

Agency for Health Care Policy and Research

The Agency for Health Care Policy and Research(AHCPR) is the successor the National Center forHealth Services Research and Health Care Technol-ogy Assessment, a long-established Federal healthresearch organization. AHCPR was designated in

1989 to focus on the link between health research,evaluations of the effectiveness of health careinterventions, and health policy (Public Law 101-239). Its authorizing legislation specified that theagency should pay particular attention to research,demonstration, and evaluation activities related tothe delivery of health care services in rural areas.

AHCPR has carried out both intramural and

extramural research on rural health topics for thepast two decades. Studies funded in the 1970sevaluated a variety of approaches for building andstrengthening rural health care delivery systems,while in the 1980s projects concentrated on ruralhospital issues (e.g., costs and viability) and on thehealth care needs of specific populations (e.g.,minorities, migrants, Native Americans) (463). Inresponse to a congressional mandate, AHCPR sup-

ported a number of studies, presented at a conference

with 1989 funds included studies of:

q

q

q

q

q

q

rates of hospitalizationCHC users in Maine;health care access forNebraska;use of alternatives to

among CHC and non-

uninsured residents in

traditional health careservices by rural elderly, poor, and black populations;urban/rural differences in the use of health andsocial services by elderly individuals;the effectiveness and success of various ruralhospital management strategies; and

variations in resource use, costs, and outcomesamong obstetric providers in Washington.

Office of Rural Health Policy

The Office of Rural Health Policy (ORHP),established in August 1987,

27is located within

HRSA and advises the Secretary of DHHS on avariety of rural health issues, particularly thoseregarding Medicare and Medicaid payment, availa-bility of health professionals, and access to care in

rural areas (688). As a component of this activity, theOffice provides staff support to a committee, com-posed of members of both the public and privatesectors. This committee advises the Secretary of DHHS on the priorities and strategies that should beconsidered in addressing the problems of financingand providing health care in rural areas.

In addition, the Office administers the Rural

Health Research Center grant program, managessome rural health demonstration grants, and servesas an information broker for rural health careresearch findings and evaluations of innovativeapproaches to rural health care delivery. Under theRural Health Research Center grant program (au-thorized in Public Law 100-203), ORHP in Septem-ber 1988 awarded grants to five university-basedresearch centers to collect and analyze information,conduct applied research on rural health, and dis-


seminate the results.28

The activities being con- q

ducted by these centers include:

q

q

q

establishing a clearinghouse for State-levelinformation on rural health initiatives and State

laws affecting rural health;q

documenting the distribution of registered nursesin rural areas and issues relating to rural nursing

q

ti

examining patterns of change in rural residents’use of hospital services;describing the condition and roles of ruralhospitals;

examining the availability of obstetric care inrural areas; andsurveying rural migrants and Mexican nation-als near the southwest border to determine their



q

q

practices;tracking the geographic variation in per capitaexpenses of Medicare beneficiaries in ruralareas; The

als near the southwest border to determine theirhealth care utilization patterns and financialaccessibility to care.

Omnibus Budget Reconciliation Act of 1989compiling a national rural health atlas reflect- (Public Law 101-239) appropriated funds for up toing the health status and health services availa- four research centers in addition to the five already

ble to rural residents; receiving funding.

~~e five centers rmeiv~g grants me: me center for Rural Health Services at the University of No@ IXkOta, Grand Forks; Mmhileld ~~c~

Research Foundation, Marshfield, Wiscons@ Health Services Research Center at the University of North Chrohna, Chapel Hill; Universky o

Washington School of Medicine, Seattle; and the University of -A-rizcma Schooi of Medicine, Tbcson.



Chapter 4

The State Role in Rural Health

CONTENTS Page

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87OVERVIEW OF STATE RURAL HEALTH ACTIVITIES: RESULTS OF AN



OTA SURVEY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

General Description of Responding Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Rural Health Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91Ranking of Selected Rural Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Current and Future State Activities in Rural Health.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

A CLOSER LOOK AT STATE RURAL HEALTH ACTIVITIES . . . . . . . . . . . . . . . . . . . . . . . . . . 100

State Offices of Rural Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100Selected Examples of State Legislative and Administrative Activity . . . . . . . . . . . . . . . . . . . . . . . 101

SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Box Box Page

4-A, Recently Created State Offices of Rural Health: Two Examples . . . . . . . . . . . . . . . . . . . . . . . . 103

FiguresFigure Page

4-1. State Use of Provider Recruitment and Placement Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934-2. State Involvement in Rural Health Research Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 954-3, Stated Involvement in Rural Health Systems Coordination and Implementation

Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 964-4. State Involvement in Rural Health Educational Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 974-5. State Priorities for Rural Health Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

TablesTable Page

4-l. Potential State Roles for Improving Rural Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 874-2. List of Respondents to OTA’s 1988 Survey of State Rural Health Activities . . . . . . . . . . . . 884-3. Changes in State Rural Health Budgets, 1987-89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 894-4. Funding Sources of Organizations Responding to OTA’s Survey of State

Rural Health Activities, 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..,.... . . . 904-5. Overall Activity Strength of States Responding to OTA’s Survey of State

Rural Health Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

4-6. State Provider Recruitment and Placement Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 924-7, State Involvement in Rural Health Technical Assistance Activities . . . . . . . . . . . . . . . . . . . . . 944-8. Selected State Rural Health Activities From OTA’s Survey of State Rural Health

Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 994-9. Selected Rural Health Activities: Comparison of "More Rural” and "LessRural”

States and States With and Without Identifiable Offices of Rural Health (OHS). . . . . . . . 1004-10. State Ranking of Six Major Rural Health Care Delivery Issues, 1989 . . . . . . . . . . . . . . . . . . . 1014-11. Relationship Between States’ Perception of Major Rural Health Issues and Specific

Rural Health Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1024-12. States With Offices of Rural Health, 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

4-13. Four Examples of State Task Forces and Committees Created To Address Rural HealthIssues . . . . . . . .....,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Chapter 4

The State Role in Rural Health

INTRODUCTION

Faced with dwindling Federal resources, Stateshave assumed more responsibility for defining andaddressing their health care needs. The potential role

OVERVIEW OF STATE RURAL

HEALTH ACTIVITIES: RESULTS

OF AN OTA SURVEY



g pfor States in improving rural health services is largeand diverse (table 4-l). To carry out this role, severalStates have created State offices of rural health, andmany have developed specific legislative and ad-ministrative initiatives. In some States, sweeping

changes in rural health care policy and delivery havedeveloped quickly. In others, policymakers andplanners are only just beginning to address ruralhealth issues.

This chapter presents an overview of State ruralhealth activities, discusses these activities, andprofiles selected recent State rural health legislativeinitiatives.

1

OTA conducted a survey of States in fall 1988 toidentify: 1) those rural health issues States perceiveto be most critical, and 2) specific activities andprograms that States had undertaken during the past3 years to address these issues. The survey targeted

organizations that were either State-based or State-supported and that were involved in rural healthplanning, development, research, or policy. All 50States responded to the survey.

The survey defined a State activity as any activityin which the State was involved directly (throughregular paid staff time or State budget authority) orindirectly (e.g., through contract to an outside

Table 4-l—Potential State Roles for Improving Rural Health Services

Developing rural health policysEstablish special office, task fore e, or commis –

sionsConduct special studies

Providing technical assistance and information torural providers and community groups

sProvide technical assistance to promoteregionalization and integration of services

sProvide information to providers and community

groupsAssessing and changing State laws and regulations

Assess impact of regulatory requirements for

small and rural hospitals

Change State licensure laws and regulations to

promote greater flexibility in the staffing and

configuration of rural medical facilities

Change certificate-of-need requirements or

create special exemptions for rural medical

facilities

Change State scope-of-practice laws to permit

greater use of midlevel practitioners in rural

areasCreate more flexibility in the definition of

“continuous service” for emergency medicalfacilities

~nt~ needed servicessEstablish criteria for designating “essential”rural providers or for intervening in possibleclosure of rural hospital

= Provide grant funds to promote linkages between

facilities and to stimulate the development of

new models and approaches

sCreate special capital equipment funds to assist

hospitals needing access to low-interest capital

loans

Increasing the availability of health professionalss

s

s

Establish scholarship programs for rural pro-

viders

Fund rural preceptorship programs

Permit and encourage the cross-training and mul-

tiple certification of allied health profes-

sionals

Increasing payment or financingsExpand Medicaid eligibility for the poorsIncrease Medicaid reimbursement to reflect “true

costs” of providing services in rural areas

sStimulate private sector funding through sub-

sidies for health insurance for low-income ruralworkers

r Change reimbursement to provide more incentives

for providers practicing in rural areas

sIncrease reimbursement to rural clinics provid–

ing Medicaid–covered ambulatory services

sIncrease reimbursement for rural emergency medi–

cal services and transportation services

SOURCE: D. Helms, “The Role of the State in Improving Rural Health Care,” paper presented at a rural healthcare workshop sponsored by the National Center for Health Services Research, Rockville, MD. NOV. 29.

1988.

lo~ers~tem~h~~ activitieSmdiScu5Sed fic.hs. 7,8, 11, 13, and150ftis l&pOfi.

-87-20-810 0 - 90 - 4 QL3


Table 4-2—List of Respondents to OTA’s 1988 Survey of State Rural Health Activities

Number of

State respondents Entities whose activities were reporteda

Alabama

AlaskaArizona

Arkansas

California

1

11

2

2



California

Colorado

Connecticut

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

NebraskaNevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

2

1

1

1

1

2

1

1

1

1

1

1

1

1

1

2

1

1

1

1

2

1

12

1

1

2

1

2

2

1

3

1

2

1

1

2

Chapter 4-The State Role in Rural Health q 89

Table 4-2—List of Respondents to OTA’s 1988 Survey of State Rural Health Activities-Continued

Number of

State respondents Entities whose activities were reporteda

Tennessee 1 *

Texas 3*

*

*

Utah 1 *

Vermont 1 *

i i i *



Virginia 1 *

Washington 1 *

West Virginia 1 *

Wisconsin 1 *

Wyoming 1 *

aBoldface type indicates the entity for which the respondent reported activities. Normal type indicates the

location of that entity within the State government or other organization.SOURCE: Office of Technology Assessment, 1990.

organization). The survey asked central State healthadministrative officers in the targeted organizationsabout State activities in areas such as technicalassistance, special rural health initiatives, personnelissues, and research. It did not explicitly attempt toobtain information about programs not formally

linked to the State, although some respondents usedopen-ended questions to describe such programs. Adescription of the survey methods, a copy of thesurvey instrument, and a list of addresses of surveyrespondents are included in appendix D of the report.

General Description of Responding

Organizations

Table 4-2 shows the entities whose activities arereflected in the survey.

Organizational Base and Authority

Of the 65 responding organizations in 50 States,57 were State-based, 7 were university-based, and 1was a private nonprofit organization created throughGovernor’s action that later gained legislative author-ity. Most of the organizations (62 percent) had been

established through State legislative authority, witha substantial minority (35 percent) establishedthrough administrative authority.

Funding

States inconsistently reported financial data,2but

OTA was able to analyze State rural health activity

Table 4-3-Changes in State Rural Health Budgets a,1987-89

Percent change in rural

health budgeta

, 1987-89 Number of Statesb

-41 or less . . . . . . . . . . . . . . . . . . . . . . . . . . 2

-21 through -40 . . . . . . . . . . . . . . . . . . . . . . 3-1 through -20 . . . . . . . . . . . . . . . . . . . . . . 3

0 through +20 . . . . . . . . . . . . . . . . . . . . . . . 13

+21 through +40 . . . . . . . . . . . . . . . . . . . . . . 4

+4 I or greater . . . . . . . . . . . . . . . . . . . . . . . 8-----------------------------------------------------

Total number of States reporting . . . . . . 33

aRespondents were asked to provide figures reflecting

their total budget for rural health activities for

1987, 1988, and 1989. Methods of budget calcula-

tion varied considerably. For multiple respondent

States, budget figures for all respondents were to-taled and the percent change was calculated from

the total.b

Responses from only 33 States were used in this

analysis because some States were unable to provide

comparison data for 1987.

SOURCE: Office of Technology Assessment, 1990.

funding sources for 1989 for 42 States and total ruralhealth budget changes nom 1987 to 1989 for 33

States.3

Although the majority of States reportedmodest increases in their total rural health budgetsfrom 1987 to 1989, the budgets of nearly one-fourthof the States (8 of 33) had decreased (table 4-3).States’ dependence on Federal, State, and otherfunding sources varied widely. The proportion of funding derived from Federal sources ranged from 0

2Seeapp.D.

qForS@teswi~more& oneresponden~ weighted percentages wmedet erminedifallrespondents hadprovided fmncialdata.Lf allrespondentsImdnotprovided da@ data from that State were regarded asmissing.






Table 4-6--State Provider Recruitment and Placement Activitya

Range of number Number of

Number of States that recruited providers of placements in States that

Recruited Recruited but States that placed at did not

Total & placed did not placeb least one provider recruit

Physician (MD/DO)c

. . . . . . . . . . . . . . . 35 33 2 1 - 602 14

Registered nurse . . . . . . . . . . . . . . . . 16 11 5 1 - 520 33

Nurse practitioner . . . . . . . . . . . . . . . 19 7 12 1 - 10 31

Physician assistant . . . . . . . . . . . . . . 17 7 10 1 - 12 33

Mental health professional 15 8 7 2 17 35



Mental health professional . . . . . . . 15 8 7 2 - 17 35

Dentist. . . . . . . . . . . . . . . . . . . . . . . . . . 8 8 . 0 1 - 8 42

Pharmacist. . . . . . . . . . . . . . . . . . . . . . . 3 3 0 1 - 27 47

Physical therapist. . . . . . . . . . . . . . . 4 4 0 1 - 12 46

Paramedic. . . . . . . . . . . . . . . . . . . . . . . . 1 1 0 19 - 19 49

Other providersd

. . . . . . . . . . . . . . . . . 10 10 0 1 - 194 40

astates were asked t. report the number of providers recruited and placed during the Past 3 Years. The end

date of this period was late 1988 or early 1989, depending on the State. Numbers reflect only recruitment

and placement activity carried on by the responding State organizations, which may only be a small

proportion of all such activity in the State.bThis indicates the n~er of States that recruited a particular type of provider but did not Place anY during

the past 3 years. For example, if a State recruited 9 physicians and only placed 3, it would not be counted

in this column but rather in the second column of this table. In this sense, it is an underestimation of the

number of States that had difficulty filling all of the positions for which they were actively recruiting.cData not available for one State.dother providers recruited include:

nutritionists, licensed practical nurses, occupational therapists, speech

therapists, dental hygienists.


Provider Recruitment and Placement—Thirty-eight of the 50 States (76 percent) reported that theyhad engaged in provider recruitment and placementactivities.

9Of these, more reported recruitment and

placement of physicians than of other health profes-sionals (table 4-6). The number of providers placedvaried widely. One State had placed only a single

physician during the past 3 years, while another hadplaced 602. A considerable number of States re-ported unsuccessful attempts to recruit nurse practi-tioners and physician assistants. States most fre-quently recruited through the National Health Serv-ice Corps (NHSC), service-contingent State scholar-ships, State loan forgiveness/repayment programs,and placement services (figure 4-l). Nine Statesreported using other types of financial incentives

(e.g. recruitment travel assistance) to attract andplace health personnel.

Regional comparisons showed the South to beparticularly active in provider recruitment and place-ment. More States in the South (63 percent) werelikely to use the NHSC as a recruitment source than

were States in the Northeast (22 percent), West (50percent), and Midwest (42 percent).

10Southern

States were also more than twice as likely as Statesin other regions to recruit through State loanforgiveness/repayment and scholarship programs.Other recruitment methods used by States included:

q

q

q

q

q

q

a program that provided travel allowances to

prospective physicians for visits to practicesites (North Carolina),

a bonus of $20,000 to any physician willing tolocate in a designated shortage area (Okla-homa),

a loan fund to help physicians and communitiesestablish rural primary care clinics (Arkansas),

a program to provide equipment and startup

funds for physicians locating in areas eligiblefor the State’s loan forgiveness program (NewYork),

establishment of rural placement offices inState medical schools (Oklahoma),

a tuition reimbursement program for physicianslocating in communities of 2,500 or fewer

%esenumbers reflect only recruitment and placement activity camied onby the responding State organizations, which may only be asmall

percentage ofall such activity intestate.l~s~ybearefl~tionof~erelatiVely~ghconcen@ationof~ten~lyqud@gmSCplaCementSiteSh~eSOU~COmpWd~~O~er~@O~

(seech. 11).

Chapter 4--The State Role in Rural Health q 93

Figure 4-l-State Use of Provider Recruitment and Placement Methodsa

Method

National Health

Service Corps

2 3

State scholarships inexchange for service 15

in rural areas



State loan forgivenessrepayment programs

Other financialincentives

Placement service 29

Other recruitmentmethods

o 10 20 30 40 50

Number of States using method

a~at= were ~k~ tO ~ew~ “eth~ “~~ tO ~ait ~~r~Onnel during the pat 3 years- The end date of this period W* late 1988 or early 1989, depending

on the State.SOURCE: Office of Technology Assessment, 1990.

residents (South Dakota),payment of malpractice insurance premiumsfor obstetricians (Tennessee),requirements that State medical residency pro-

grams actively recruit physicians to under-served areas (Texas),newsletters advertising available positions,low-interest loans in exchange for service inrural areas, anda locum tenens

ll program for nurse practition-

ers and physician assistants.

In telephone conversations and in open-ended re-sponses, some respondents indicated that reductionof the Federal NHSC program had had a negativeimpact on physician availability in undeserved ruralcommunities.

Financial Assistance to Local Organizations--Thirty- five States (70 percent) were offering some form of financial assistance to local organizations and indi-viduals. Only 3 were providing loans to localorganizations, while 9 were providing funds on a

matching basis, and 31 were providing direct un-

matched subsidies. Fifteen States were providingother types of financial assistance. States in theNortheast and South were more likely to haveprovided local financial assistance than were those

in the Midwest and West. Some examples of Statefinancial assistance include:

provision of living allowances to nursing andmedical students while they are in clinicaltraining at rural practice sites (Arizona),

loan fund to support the development of localservices and improve access to services (Ar-kansas),

a Mortgage Loan Insurance Program to helphealth facilities finance capital expenditures atreasonable cost (California),

matching funds for local transport systems fornewborn infants (Delaware),

rural medical school demonstration projects(Florida), andfunds for recruitment and retention of primarycare providers in community health centers

(Tennessee).



Chapter 4--The State Role in Rural Health q 95

Figure 4-2-State Involvement in Rural Health Research Activitiesa

Research topic

Health personnelin rural areas

Rural healthservices utilization

Health status ofrural populations

Rural health systemscoordination



coordinationInsurance coveragein rural population

Medical liability insur-ance costs/availability

New health technologyin rural areas 14

Quality of care inrural areas\ availability

Rural hospitals 30

Other rural healthrelated research topicsb

t I I I T I

o 10 20 30 40 50

Number of States that conducted research on topicsaROSpOndentS reported activitkstlley had been directly involved in at anytime during the past 3 years. The end date of this period [email protected] late 1988 or e~y 1989,

depending on the State.b~her ~r~ hea~h.related top~ inc[ud~: border health uti[i~ation patterns (~); alli~ health personnel in ~ral hospitals (FL); emergency n’ldd SerVkOS

(GA); pennatal care access (GA); family planning (GA); access to pharmacy services (GA); knowledge and practices in underserved populations regardingacquired immunodeficiency syndrome (GA); geriatric care (Hi); long-term care (MD); travel time between rural hospitals (MD); frontier health services (NM,SD); Federal and State-funded primary care-centers (TN); site-sp&ific epidemiologic studies (TX); transportation systems in shortage areas (WA).

Walid responses were received from all 50 States.


tions, nursing homes, laboratories, and pharmacies.Over one-half of States had promoted alliancesbetween hospitals and other health providers, whilenearly four-fifths of States had promoted alliancesthat involved only nonhospital providers.

Nine States reported involvement in other types of rural health systems coordination and implementa-tion

q

q

q

q

activities, including:

the development of adolescent health servicesand prehospital emergency medical services(Hawaii);the Iowa Rural Work Group, which provided aforum for discussion of a variety of ruralconcerns among representatives of Federal andState agencies;defining “rational service areas” for primarycare to assist in State and local planning efforts

(Nevada);development of multicounty health districts tohelp consolidate and integrate health resources

qin contiguous counties (Texas); andgrant programs to encourage formation of alliances between health service facilities (NewYork).

Educational Activities-Forty-five States wereconducting rural health-related educational activi-ties, with five States reporting no such activities.Over two-thirds were involved in health professionseducation for rural providers, and well over one-half were involved in providing continuing education forrural health professionals. Over one-half had organ-ized Statewide rural health conferences (figure 4-4).

Legislative Affairs--Forty-four States reportedinvolvement in legislative affairs. Thirty-four haddeveloped task forces or committees to address ruralhealth issues. Thirty-nine of the responding organi-zations had worked with State legislatures and/or

legislative committees on rural health issues. Sixreported other types of involvement in legislativeaffairs related to rural health. States in the Northeast











Chapter 4--The State Role in Rural Health . 101

Table 4-10-State Ranking of Six Major Rural Health Care Delivery Issues, 1989 a

Number of Statesbc

g iving the issue a ranking of:

Issue (1) (2) (3) (4) (5) (6) (7)

A. Health provider issues (e.g., shortages,

recruitment/retention) . . . . . . . . . . . . . . . . . . . . . . . . . 22 13 10 4 1 0 0

B. Meeting the needs of special populations . . . . . . . . . . 10 10 8 14 5 3 0

C. Payment issues (e.g., Medicare, insurance

coverage of rural populations). . . . . . . . . . . . . . . . . 10 14 7 13 6 0 0

D. Medical liability insurance costs/

availability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 7 6 5 9 18 1



E. Services issues (e.g., hospital closures/

restructuring, systems planning and

development). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5 15 5 14 8 0

F. Quality of care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1 5 9 13 20 0

G. Other issuesd

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0 0 1 2

--------------------------------------------------------------------------------------------------------------

Number and percent of all States ranking issue among the top 3:

(A) (B) (c) (D) (E) (F)

U.S. total [50]e

. . . . . . . . . . . . . .

Northeast [9] . . . . . . . . . . .

South [16] . . . . . . . . . . . . . .

Midwest [121 . . . . . . . . . . . .

West [13].. . . . . . . . . . . . . .

“More rural” States [15]

f

. . . . .“Less rural” States [35]f

. . . . .

States w/ an ORH [12]g

. . . . . . . .

States w/o an ORH [38]g

. . . . . . .

45

9

12

11

13

1332

11

34

(90%) 28

(loo%) 6

(75%) 11

(92%) 5

(100%) 6

(87%) 10(91%) 18

(92%) 7

(90%) 21

(56%)

(67%)(69%)

(42%)(46%)

(67%)(51%)

(58%)

(55%)

31

3

9

9

10

1219

8

23

(62%)

(33%)

(56%)

(75%)

(77%)

(80%)(54%)

(67%)

(61%)

17

25

5

5

215

6

11

(34%)

(22%)

(31%)

(42%)

(38%)

(13%)(43%)

(50%)

(29%)

23

4

9

5

5

617

5

18

(46%) 8 (15%)

(44%) 3 (33%)

(56%) 2 (13%)

(42%) 1 (8%)

(38%) 2 (15%)

(40%)2 (13%)

(49%) 6 (17%)

(42%) 1 (8%)

(47%) 7 (18%)

aDate of ra~ing may be late 1988 or early 1989, depending on ‘he ‘tate”

bvalld responses were received from all 50 ‘tates.C

For multiple respondent States, results are based on the response of a single respondent in each State who

was identified as most knowledgeable about and central to State rural health activities.

‘A blank line was provided on which respondents could list an additional “general issue” and incorporate it

into the ranking scale accordingly. The three “other” issues listed by respondents were: alternative

delivery models; availability of obstetrics services; unspecified.

eN~ers in brackets denote n~er of States within each region or category.‘States were classified as “more rural” or “less rural” depending on the percentage of their population

residing in nonmetro areas in 1986 (“more rural”=

over 50 percent; “less rural”=

0–50 Percent. (See app.

D for a list of States. )

gAn “office of rural health” (ORH) was either identified as such by a respondent or was known to be an office

whose primary responsibility was to administer to the health needs of rural areas of the State. (See app. Dfor a list of ORH States and an explanation of how these States were identified. )


tion dissemination, advocacy, health systems devel-

opment and integration, and direct service (426).

State ORHs may also be of value in coordinatingand implementing Federal rural health initiatives. Inthe 1988 NRHA survey of State ORHs, respondentssaw the Federal Office of Rural Health Policy asplaying a central role in dissemination of informa-tion regarding funding sources for rural healthprograms and activities, while State ORHs were

seen as playing a critical role in determining Stateand regional rural health needs and guiding a morerational allocation and coordination of resources at

these levels. Respondents also felt that the Federal

office could assist in the development of new StateORHs by helping State governments identify poten-tial resources and other State models. Examples of two States that have recently created ORHs arepresented in box 4-A.

Selected Examples of State Legislative and

Administrative Activity

The creation of special task forces or committeesis a common step towards a comprehensive exami-nation of State rural health issues. Thirty-four States



Chapter 4--The State Role in Rural Health . 103

Table 4-12-States With Offices of Rural Health, 1990

States with Offices of Rural Health:

State Location of ORH

Arizona University

Arkansas State agency

California State agency

Connecticutb

State agencyGeorgia

c

State agency & university

Illinoisc

State agency

Iowaa

State agency

Kansasc

State agency



Nebraskaa

Skate agency

Nevada University

New Mexico Not-for-profit organization

North Carolina State agency

North Dakota University

Oregon State agency

South Dakotac

State agency & university

Texas University

Utah State agency

Washington Area Health Education CenterWisconsin University

-----------------------------------------------------

States interested in or planning to establish

Offices of Rural Health:

Alabama Minnesota Alaska Mississippi

d

Michigan Montana

aEstablished since 1986.

b

Office of rural and urban health.cEstablished since 1988.d A 1990 bill (S.B.2398) pending in the MississippiState Legislature would create an office of ruralhealth within the State Department of Health. Thereis an existing Rural Health Research Program in theUniversity of Mississippi School of PharmaceuticalSciences, but it is not involved in rural health

policy or planning.SOURCE: Office of Technology Assessment, 1990. Based

on data from National Rural Health Associ–

ation, “Report of the Task Force on Offices

of Rural Health and State Rural Health Associations,” National Rural Health Asso-ciation, Kansas City, MO, Aug. 12, 1988, asupdated by OTA.

reported that they had developed task forces, most

commonly through administrative action of theGovernor’s office. Table 4-13 provides some exam-ples of State task forces and committees and theirresponsibilities. The experiences of New York andTexas, described below, illustrate the role of task forces in catalyzing legislative and administrativeaction on rural health issues.

NewYork

Both the State legislature and the State Depart-ment of Health have recently examined rural healthcare issues in New York. In spring 1987, the

Legislative Commission on Rural Resources held a

symposium to assess the rural health care system andto design a framework to ensure access to ruralhealth for the next 20 years. The symposiumidentified three major areas needing legislative and

. .administrative attention:

q

q

need for regulatory flexibility (e.g., grantingrural hospitals a waiver from the CON process),

need for reimbursement and financing mecha-nisms that more accurately reflect costs andimprove access to capital, and






system of coordinated primary care servicesaccessible to all area residents (594).


States have both a high level of involvement inrural health activities and a significant degree of dependence on Federal funding for those activities(table 4-3). The level of effort States are devoting torural health issues varies dramatically and does notnecessarily correspond with States’ degree of rural-

nificant capital if they were to have a pronouncedand prolonged impact.

When asked what activities or programs they

would like to see in the future to address rural healthissues, respondents to this survey often suggested anactive Federal role. Activities such as the creation of State ORHs; development of rural health policies,plans, and standards; improvement of health insur-ance coverage; Medicaid expansion or reform; ruralh l h di i d k d l



ness or perceived level of need. Differences between‘‘more rural’ and “less rural” States emerged

primarily in the States’

perceptions of major rural

health care problems (table 4-10) rather than in theirlevel of rural health-related activity. While someStates boast a variety of successful initiatives andprograms, other States—and, notably, some Statesin which a large proportion of the population isrural-have not mobilized to address their particularrural health problems. These States might especiallybenefit from Federal guidance, encouragement, andcontinued support.

Because the OTA survey did not attempt todescribe the degree to which reported activities werefelt to have been successful by the States, or thesources of funding for specific activities, it isimpossible to distinguish clearly between the Fed-eral and the State roles. A study conducted by theFederal Bureau of Health Professions in 1986 foundthat State support for health professions distribution

programs increased significantly during the first half of the 1980s (685).

19However, OTA’s survey found

that States still rely heavily on Federal funds tosupport a variety of existing rural health activities.

Most States identified provider recruitment andplacement issues as high priorities, but most did nothave programs (e.g., service-contingent loan forgive-ness/repayment and scholarship programs) com-monly believed to be most effective in addressingthese issues. Because scholarships and loans arecostly, such programs would probably require sig-

health systems coordination and network develop-ment; loan repayment or forgiveness and scholarshipprograms; and availability of rural-oriented health

professions education were frequently mentioned. AFederal role is possible, if not implicit, in all of theseinitiatives.

Recent State legislative activity on rural healthissues has ranged from energetic to nonexistent.Active States can provide valuable models for lessactive States, and certain State Programs ’could serveas models for broader Federal initiatives. OTA’s

survey of State rural health activities reveals somesignificant regional and State differences that maybe useful in targeting Federal resources.

State ORHs provide focal points for State ruralhealth activities and programs and can improve thedevelopment and coordination of local, State, andFederal efforts. The degree to which State agenciescan effectively direct such offices, however, willvary depending on financial and organizationalfactors. The distribution and organization of currentState ORHs suggests that any Federal support for thecreation or operation of State ORHs should beflexible with regard to location of the ORH withinthe State. Some States currently without ORHsmight consider alternatives to the State agency-based model (e.g., university-based ORHs like thosein Arizona and North Dakota). South Dakota andGeorgia are examples of States whose ORHs arebased both within a State agency and a university.

Part III



Rural

Availability of

Health Services



BoxesBox Page5-A. The Hill-Burton Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1195-B. The Hill-Burton Uncompensated Care Obligation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

FiguresFigure Page

5-1. Nonmetropolitan Hospitals by Census Region, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135-2. Ownership of Nonmetropolitan Community Hospitals, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135-3. Short-Term Hospital Beds to Population Ratio, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1215-4. Certified Rural Health Clinics, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1295-5. Sources of Payment for Services in Rural Federally Funded Community Health Centers,

1984 1986 and 1988 142



1984, 1986, and 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1425-6. Closure of U.S. Community Hospitals by Metropolitan/Nonmetropolitan Status,

1981-89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

TablesTable Page

5-1. Community Hospital Size and Utilization, by Metropolitan/Nonmetropolitan Status,1984-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

5-2. Number of Community Hospitals by Metropolitan/Nonmetropolitan Status and Bed Size,1984-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

5-3. Most Common Selected Services Available in Nonmetropolitan Community HospitalsWith Fewer Than 300 Beds, by Bed Size, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

5-4. Intensive Care Capability and Selected Diagnostic and Treatment Services Availablein Community Hospitals, by Hospital Location and Bed Size, 1987 . . . . . . . . . . . . . . . . . . . . 115

5-5. Long-Term Care Services Provided in Nonmetropolitan Community Hospitals, 1987 . . . . . 1165-6. Total Medical Staff in Community Hospitals With Fewer Than 300 Beds,

by Hospital Location, Type, and Bed Size, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175-7. Changes in Utilization of Community Hospitals by Hospital Location and Bed Size,

1984-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175-8. Utilization of Nonmetropolitan Community Hospitals by Hospital Type and Bed Size,

1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1185-9. Distribution of Hill-Burton Short-Term Hospital Projects and Population,

by Community Size, 1948 -71 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1205-10. Community Hospital Beds per 1,000 Population and Occupancy by Hospital Location,

1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1205-11. Community Hospital Outpatient Utilization by Hospital Location, 1984-88 . . . . . . . . . . . . . 1235-12. Select Ambulatory Care Services Provided in Nonmetropolitan Community Hospitals

by Bed Size and Hospital Type, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1235-13. Number of Federally Funded Community Health Center (CHC) Grantees and Service Sites

by Rural/Urban Status and Region, 1984-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . +.. . . . 1255-14. Utilization of Rural Federally Funded Community Health Center Grantees and Service Sites,

1984-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1275-15. Primary Care Physician Utilization in Rural Federally Funded Community Health Centersby Region, 1984-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

5-16. Number of Certified Rural Health Clinics, and Nonmetropolitan Counties in Which ClinicsCould Qualify for Certification, by State, 1989.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

5-17. Average Days in Patient Accounts Receivable for Community Hospitals, by HospitalLocation and Bed Size, 1984 and 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

5-18. Aggregate Uncompensated Care in Community Hospitals by Hospital Location andBed Size, 1984-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

5-19. Sources of Net Patient Revenue of Community Hospitals, by Hospital Location, 1986 . . . 132







Chapter 5--Problems and Trends in Rural Health Services q 113

Figure 5-1--Nonmetropolitan Hospitals by CensusRegion,

a1986

West South Central

West

Eas

North Cent22.1%

t South Cer11 6%

® Mountain9.7%

‘:::’

New England

‘73.2%

-- - Mid Atlantic

i 3.6%

/

Ch

Figure 5-2-Ownership of NonmetropolitanCommunity Hospitals,a 1987

City/county or both

Hospital districtor authority

16.5%

State0.7%

urch-operated

(nonprofit)

L

. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .7.8%

. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . ., ::::::::::::::::: :::::::::::::

For-profit10%



11.6%South Atlantic

13.3%

East North Central

13.6%Rural hospi ta ls

(2,638)

aAs defined by the U.S. Census Bureau. See app. Ffor geographk displayof regions.

SOURCE: Office of Technology Assessment, 1990. Data from M. Merlis,“Rural Hospitals,” U.S. Congress, Congressional ResearehService, Washington, DC: no. 89-296 EPW, May 2, 1989.

ment authorities owned another 42 percent, and

for-profit investors the remaining 10 percent (625).

A rural hospital’s type of ownership is related toits size. Hospitals with 100 or more beds werepredominantly private nonprofit facilities, whereasover one-half of hospitals with fewer than 50 bedswere owned by State and local governments (625).The large number of rural community hospitalsunder local government authority probably indicates

the importance of community-subsidized support forthese facilities.

Type of ownership also varies by the location andtype of rural hospital. A majority of hospitals infrontier areas (56 percent) were government-ownedin 1987, but just 21 percent of rural referral centers(RRCS)

5were government-owned. Conversely, 71

percent of referral centers v. only 42 percent of frontier hospitals were privately owned, nonprofitfacilities. The ownership profile of Medicare-designated sole community hospitals (SCHs) (seech. 3) was comparable to that for rural hospitals ingeneral. Just 3 percent of both frontier hospitals andSCHs had for-profit owners; RRCs had a slightlyhigher proportion (7 percent) (625).

Other nonprofit40.2%

Wommunity hospitals defined here as all non-Federal, short-stay, nonspe-

cialty hospitals (see app. C).

SOURCE: Office of Technology Assessment, 1990. Data from AmericanHospital Association’s 1987 Annual Survey of Hospitals.

In 1987, about 19 percent of rural hospitals werecontract-managed (see ch. 6), compared with 8

percent of urban hospitals. The number of ruralfacilities under contract management increased 15percent from 1984 to 1987, suggesting a change intraditional forms of governance for many hospitals(e.g., greater involvement in hospital operations byinterests outside the community) (30).

Hospital Scope of Services

There are few in-depth analyses of the nature of medical services offered by rural community hospi-tals, or their dependence on hospital size, location,and other factors. Shorten, in a national study of hospitals in multihospital systems

6from 1984 to

1987, found that rural hospitals offered fewerservices (average 17) than urban hospitals (average22). However, rural hospitals were found to provide

a variety of services (particularly outside the hospi-tal) targeted to the elderly (418). Much of thedifference in the scope of services of rural and urbanhospitals appears to be due to smaller rural hospitalsize. A study of hospitals in 13 geographicallydiverse States found that rural hospitals as a groupoffered 30 percent fewer services than did urbanhospitals. However, no significant differences were


found in the number of services between rural andurban hospitals of the same size (590).

In a recent study of the service mix of both ruraland urban hospitals in 1985, the provision of specificservices was linked to local demand, providercapabilities, and mission or strategy of the hospital.For example:

q

q

q

Rural hospitals provided more long-term careservices than did urban hospitals.Emergency and obstetric services were presentin nearly every rural hospital.Occupational therapy was most likely to be

have an ultrasound unit, compared with 77 percentof rural hospitals in this group).

Complex Acute-Care Services

The proportion of hospitals offering intensive careservices differs by location and decreases by bed size(table 5-4). Although 62 percent of all rural hospitalswith fewer than 300 beds have medical/surgicalintensive care units (compared with 88 percent of urban hospitals of the same size), just 19 percent of rural hospitals with fewer than 25 beds have this

i O l ll f ll h i l i h



q

q

Occupational therapy was most likely to bedelivered by smaller urban hospitals that could

target specific needs of the market.Most hospitals with fewer than 50 beds did notprovide cardiac intensive care, an expensivespecialty service.

Long-term care services were particularly prominentin smaller rural hospitals, where the hospital-basednursing home often had three to five times as manypatients as the acute-care part of the hospital (236).

Rural hospitals generally provide less highlyspecialized care and perform fewer complex proce-dures than do urban hospitals. Number of hospitalbeds and the ability to obtain a regular surgeonappear to be critical factors in whether rural hospitalsprovide inpatient surgery. Hart et al. found thatprocedures in hospitals with fewer than 100 bedswere generally common ones of relatively low risk and complexity. Rural hospitals with fewer than 25

beds provided very little inpatient surgery; 79percent of these hospitals performed fewer than 100annual inpatient operating room surgeries. By com-parison, over two-thirds of all rural hospitals with atleast 50 beds performed more than 100 surgeries ayear (236).

Common Acute-Care Services

Table 5-3 lists the most common services of

community hospitals with fewer than 300 beds in1987 (625). The likelihood that such hospitalsprovide any of these services increases as thenumber of beds in the hospital (bed size) increases.Nearly all rural and urban hospitals (over 90 percent)of this size provide an emergency department,diagnostic x-ray facility, and ambulatory surgery.The remaining common services, however, are asmuch as 40 percent more likely to be provided in

urban than in rural hospitals of a given size (e.g., 93percent of urban hospitals with fewer than 300 beds

service. Only a small percentage of all hospitals withfewer than 300 beds offer cardiac or neonatal

intensive care-services commonly reserved forlarger urban referral centers (625).

Other new and complex services are also foundless often in small than in large hospitals and in ruralthan in urban hospitals of a given size. In 1987, forexample, rural hospitals were generally less likely toprovide in-house computed tomography (CT) scan-ning, nuclear magnetic resonance imaging (MRI),

cardiac catheterization laboratory services, organtransplants, open heart surgery, and extracorporealshock wave lithotripsy (ESWL) for kidney stones(table 5-4) (625).

Mobile settings may make some expensive tech-nology more accessible to small and isolated hospi-tals. These facilities can then have periodic access toon-site technology without needing to generate thepatient volume for its full-time support. MRI andESWL are particularly attractive candidates forshared use among small hospitals. An estimated 28percent of MRI scanners in 1987 were mobile units,and manufacturers estimate that in 1990 approxi-mately one-third of ESWL equipment operate inmobile settings (489,542).

No studies have directly compared rates of technology adoption in urban and rural hospitals, but

small and nonteaching hospitals have been shown toadopt specific expensive and complex new technol-ogies less rapidly than do other hospitals. One study,for example, found that large hospitals (250 or morebeds) were much more likely than smaller hospitalsto have adopted certain sophisticated laboratoryequipment by 1980 (707). The study also found thatthe increase between 1975 and 1980 in the adoptionof endoscopes was higher for small nonteaching

hospitals, suggesting that these hospitals adopted thetechnology later than did other hospitals (which






Table 5-8-Total Medical Staff in Community Hospitals a With Fewer Than 300 Beds,by Hospital Location, Type, and Bed Size, 1987

Mean number of total hospital medical staff by bed size category

All hospitalsHospital type 6-24 25-49 50-99 100-199 200-299 under 300 beds

Metro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.7 32.8 56.7 115.0 184.5 116.0Nonmetro . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4 10.9 21.2 42.5 77.6 24.2

Sole community hospitalsb

. . . . . . . 6.2 10.1 20.4 45.3 80.2 21.5Frontier hospitals . . . . . . . . . . . . . . 4.3 6.3 11.9 22.1 9.O

c

8.3

aco-nity hospitals defined here as all non-Federal short–stay,nonspecialty hospitals (see app. C).

bAs defined for Medicare purposes (see aPP. C).cRepresents only one hospital.

SOURCE: Office of Technology Assessment, 1990. Data from the American Hospital Association’s 1987 Annual



gy , Data from the American Hospital Association s 1987 AnnualSurvey of Hospitals.

HOSPITAL UTILIZATION AND

COMPETITION

Hospital Inpatient Utilization

Inpatient service utilization in both rural andurban community hospitals has been in steadydecline since the early 1980s (see table 5-l), but

declines have been greater in rural hospitals. From1984 to 1988, admissions to rural hospitals droppedabout two and one-half times as much as admissionsto urban hospitals. While urban hospital occupancyrates dropped to about 68 percent in 1988, occu-pancy levels for rural hospitals declined nearly twiceas much to a low of 55 percent,

8despite their

relatively greater rate of bed elimination and a 7percent increase in the average length of stay (to 7.4

days) in rural hospitals. (Longer lengths of stayenhance average occupancy but not necessarily thehospital’s financial condition. Medicare, for exam-ple, usually pays a fixed rate per patient discharged,regardless of the patient’s length of stay.) Althoughthey made up 46 percent of community hospitals in1988, rural hospitals accounted for only about 19percent of all hospital admissions and inpatient days(35).

Within rural hospitals, declines in admissions andinpatient days were somewhat greater among largethan among small hospitals (table 5-7). This trend isthe reverse of that for urban hospitals (wheredeclines were generally greatest among those hospi-tals with fewer than 100 beds) (30).

By 1987, these trends had resulted in substantialdifferences in inpatient utilization among types of

Table 5-7-Changes in Utilization of CommunityHospitalsa by Hospital Location and Bed Size,1984-87

Percent change, 1984-87:

Bed size Admissions Inpatient days

Nonmetro -19.5 -15.3

6-24 -17.9 -13.1

25-49 -16.1 -12.0

50-99 -18.2 -13.6100-199 -24.4 -19.1200-299 -9.7 -8.1

300 or more -23.8 -20.1-----—---------------—— -----------------------

Metro -7.6 -10.6

6-24 -9.9 -8.2

25-49 -14.9 -14.8

50-99 -13.3 -13.1

100-199 -1.6 -3.1

200-299 -2.3 -3.9

300 or more-10.2 -13.8

acomunity hospitals defined here as all non-Federal,

short-term general and other special service hospi-

tals.

SOURCE: American Hospital Association, Chicago, IL,

unpublished data from the Annual Survey of

Hospitals, 1984-87.

rural hospitals (table 5-8). Compared with ruralhospitals in general, for example, hospitals in

frontier areas (two-thirds of which have fewer than50 beds) had less than one-third as many admissionsper hospital. Frontier hospitals also had loweraverage occupancy rates, a lower proportion of Medicare inpatient days, and a higher proportion of Medicaid days. SCHs had similar but less pro-nounced characteristics. RRCs, on the other hand,were not only larger but had higher occupancy

@ccupancyratesherearebased onthehospital’stotalnumberofbeds (boihacutecareandother).




Box 5-A—The Hill-Burton Program

Use and Distribution of Funds

Congress enacted the Hospital Survey and Construction (“Hill-Burton”) Act (Public Law 79-725) in 1946 inresponse to a widely perceived shortage of hospital beds, particularly in rural areas. States were eligible to receive

Federal matching grants to assist in surveying State needs; developing statewide plans for constructing nonprofit,nongovernmental hospitals; and constructing the facilities. Amendments to the Act in 1964 (Public Law 88-443)made construction funds available for the modernization or replacement of facilities, set minimum structural anddesign standards affecting safety and efficiency of operations, required funded hospitals and other facilities toprovide free care to persons unable to pay, and authorized studies to demonstrate the coordinated use of hospitaland other health care facilities. In 1970, a loan guarantee component was added to Hill-Burton whereby the FederalGovernment would cover a portion of the interest cost and guarantee payment of the principal of loans to fundedfacilities (335).

The legislation required State plans to abide by Federal standards of adequacy in defining bed need. Until 1965,



g q p y q y g ,such standards were simply defined as the ratio of beds to population—the number of general beds should equal

but not exceed 4.5 beds for every 1,000 residents, except in sparsely populated areas. Critics argued that such astandard was arbitrary, as demand for hospital care could vary in areas of similar population (335).

Hill-Burton sought to equalize the distribution of hospital facilities between rural and urban areas. Above aminimum amount allotted to every State, the program allocated funds based on State population size and per capitaincome. Per capita income entered the formula twice (both as a measure of a State’s bed and financial need) to giveless affluent as well as more rural States an advantage. Within States, rural areas again were to be given priority forfunds (this provision was eliminated in 1970) (131,335).

By 1974, when the Hill-Burton program was abolished, over 10,700 projects had been funded; about one-thirdwere for new facilities and the remainder for modernization. The total cost of the projects was $12.8 billion, of which

the Federal Government contributed over $3.7 billion. Over one-half of the funded projects were for new ormodernized short-term hospitals (5,787), representing 71 percent of the total amount of Hill-Burton funds. About30 percent of all hospitals built between 1949 and 1962 used Hill-Burton monies (335).

Impact on Rural Areas

As intended, Hill-Burton funds for short-term hospital projects were concentrated in less populated areas (table5-9). About 75 percent of all projects and 67 percent of total Hill-Burton funds between 1948 and 1971 were devotedto communities with fewer than 50,000 residents. Nearly 44 percent of the projects were in communities of less than10,000 residents.

Little is known about the impact of the program in rural areas of particular States. One study in Minnesotafound substantial differences in the allocation of Hill-Burton funds between urban and rural areas of the State from1950 to 1973. Average per capita funds for hospitals in rural counties were one-third greater than funds for hospitalsin urban counties; rural counties received almost twice as many general hospital beds per 100,000 residents underthe program as did urban counties. However, 13 of the 78 rural counties received no Hill-Burton support. Also, of those rural counties obtaining support, the most rural and economically disadvantaged did not receive the expectedhigher proportion of program funds. Some of these areas may have had insufficient resources to support a new ormodernized facility (264).

The Hill-Burton program did substantially increase the number of short-term hospital beds. From 1947 to 1970,short-term hospital beds per 1,000 people increased from 3.3 to 4.3 in the United States (335). By 1986, the ratio

of community hospital beds in both rural and urban areas was about 4 beds per 1,000 people, although variationamong and within individual States was substantial (see table 5-10 and figure 5-3). In 14 States, bed-to-populationratios were actually higher in rural than in urban areas (382). The Hill-Burton program had no authority to limit bedsupply. By the 1970s, it was widely perceived that Hill-Burton had actually contributed to an oversupply of generalhospital beds in many areas of the country.

Although it had a substantial effect on bed supply, the Hill-Burton program did not significantly affect theredistribution of physicians (264). Also, there is little indication that Hill-Burton’s attempt to demonstrate thecoordinated use of hospital and other health care facilities fostered the integration and regionalization of healthservices in rural communities.

20-810 0 - 90 - 5 QL3


Table 5-9—Distribution of Hill-Burton Short-Term Hospital Projects and Population, by Community Size,1948-71

Community size Total percent Percent of total Percent of 1960

( 1960) of projects Hill-Burton funds U.S. population

Fewer than 10,000. . . . . . . . . . 43.4 28.9 45.710,000-24, 999. . . . . . . . . . . . . . 19.8 22.0 9.825,000-49, 999. . . . . . . . . . . . . . 11.6 16.3 8.350,000 and more.. . . . . . . . . . . 25.1 32.9 36.2

Total . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0

NOTE: Totals may not add to 100 percent due to rounding.

SOURCE: J. Lave and L. Lave, The Hospital Construction Act: An Evaluation of the Hill-Burton Program, 1948-= (Washington, DC: The American Enterprise Institute, 1974).



Table 5-10-Community Hospital Beds per 1,000 Population and Occupancy by Hospital Location, 1986

Beds per1,000 population

Nonmetro Metro

Alabama . . . . . . . . . . . . . 4.4 5.3

Alaska . . . . . . . . . . . . . . 1.7 2.8

Arizona . . . . . . . . . . . . . 2.4 3.3

Arkansas . . . . . . . . . . . . 4.1 5.3

California. ...,... . . 2.7 3.1

Colorado . . . . . . . . . . . . 4.43.2Connecticut . . . . . . . . . 2.8 3.2

Delaware . . . . . . . . . . . . 2.8 3.8

Dist. of Columbia. . 0.0 7.5

Florida . . . . . . . . . . . . . 3.6 4.4

Georgia . . . . . . . . . . . . . 4.3 4.1

Hawaii . . . . . . . . . . . . . . 3.2 2.2Idaho . . . . . . . . . . . . . . . 3.6 2.9Illinois. . . . . . . . . . . . 4.3 4.6Indiana . . . . . . . . . . . . . 3.2 4.6

Iowa. . . . . . . . . . . . . . . . 4.4 6.2Kansas . . . . . . . . . . . . . . 6.0 4.0

Kentucky . . . . . . . . . . . . 3.75.2Louisiana . . . . . . . . . . . 3.5 4.9

Maine . . . . . . . . . . . . . . . 3.6 5.2

Maryland . . . . . . . . . . . . 3.4 3.2

Massachusetts . . . . . . . 3.7 4.3

Michigan . . . . . . . . . . . . 3.6 4.1

Minnesota . . . . . . . . . . . 6.1 4.5

Mississippi . . . . . . . . . 5.1 4.7

Missouri . . . . . . . . . . . . 3.6 5.7

Occupancy ratea

(Percent)

Nonmetro Metro

Beds per

1,000 population

Nonmetro Metro

Occupancy ratea

( Percent)

Nonmetro Metro

54 65

55 59

53 65

49 6749 63

54 6156 74

69 67

0 78

53 63

61 66

66 78

53 67

54 6649 61

53 63

47 63

61 6546 61

62 73

73 73

65 69

54 67

61 6554 67

51 67

Montana . . . . . . . . . . . . . 5.7

Nebraska . . . . . . . . . . . . 5.6

Nevada. . . . . . . . . . . . . . 2.8

New Hampshire . . . . . . . 4.0

New Jersey . . . . . . . . . . 0.0

New Mexico . . . . . . . . . . 2.5New York. . . . . . . . . . . . 4.3

North Carolina . . . . . . 3.3

North Dakota . . . . . . . . 6.9

Ohio. . . . . . . . . . . . . . . . 3.4

Oklahoma . . . . . . . . . . . . 3.8

Oregon . . . . . . . . . . . . . . 3.2

Pennsylvania . . . . . . . . 4.0

Rhode Island . . . . . . . . 3.0

South Carolina . . . . . . 3.1

South Dakota . . . . . . . . 6.4

Tennessee . . . . . . . . . . . 4.2

Texas . . . . . . . . . . . . . . . 3.6Utah. . . . . . . . . . . . . . . . 2.4

Vermont . . . . . . . . . . . . . 3.7

Virginia . . . . . . . . . . . . 3.7

Washington . . . . . . . . . . 3.2

West Virginia . . . . . . . 4.3

Wisconsin . . . . . . . . . . . 4.7

Wyoming . . . . . . . . . . . . . 4.6

Total U.S. . . . . . . . . 4.0

5.9

6.2

3.6

2.6

3.9

3.14.4

3.7

7.7

4.7

4.1

3.1

4.7

3.6

3.6

6.6

5.7

3.82.7

4.7

3.5

2.8

6.4

4.4

3.8

4.1

57 62

51 61

44 49

65 66

0 75

58 6175 82

59 69

59 63

50 66

46 63

47 59

66 71

63 76

66 71

54 63

55 66

40 5942 62

63 8162 70

44 61

57 63

61 60

51 49

55 67

aoccupancy rates are based on the hospital’s total number of beds (both acute care and ‘ther).

SOURCE: M. Merlis, “Rural Hospitals,” U.S. Congress,296 EPW, May 2, 1989.

the high bed-to-population ratios in more denselypopulated rural areas.

Other potential factors affecting changes in inpa-tient utilization include changes in medical practice,urban competition, and payment incentives.

Changes in Medical Practice--Changes in medi-

cal technology have enabled physicians and otherproviders to care for many patients in outpatient and

Congressional Research Service, Washington, DC, no. 89-

nonhospital settings. As simple low-risk cases (e.g.,cataract surgery) are increasingly cared for outsidethe hospital, the remaining inpatients are likely, onaverage, to have more serious medical problemsrequiring more intensive care and longer lengths of stay. This is probably a contributing factor in thetrends toward both lower admissions and longer

lengths of stay. In a recent study of hospital use byMedicare beneficiaries in five States from 1984 to

Chapter 5-Problems and Trends in Rural Health Services q 121

Figure 5-3-Short-Term Hospital Beds to Population Ratio, 1986 (by nonmetropolitan county)



SOURCE: T.C. Ricketts, Rural Health Research Center, University of North Carolina at Chapel Hill, NC. Analysis of unpublished Area Resource File data(provided by the U.S. Health Resources and Services Administration) conducted under contract with the Office of Technoloav Assessment. 1989

“.

and 1990.

1986, the largest declines in hospital admission rateswere for conditions that many physicians believe donot usually require hospitalization (e.g., simplepneumonia). On the other hand, rates of admissionsinvolving some degree of subspecialty care and hightechnology (e.g., heart transplants) rose slightlyduring this period. The impact of these trends is

significant for small rural hospitals. Those caseswinning less consensus on the need for hospitaliza-tion typically represent the largest proportion of admissions to these hospitals (134).

Attractiveness and Utility of Urban Resources—The more rapid adoption of new, sophisticatedtechnologies by urban hospitals may lure ruralresidents who perceive these hospitals to be provid-

ing superior care. Also, many rural residents travelto large urban hospitals to obtain specialized care not

locally available. A recent study found this occur-rence to be increasing. From 1984 to 1986, thevolume of ‘‘technology-intensive’ Medicare ad-missions in a five-State sample of rural hospitalseither declined or rose at a much slower rate than thevolume of such admissions to urban hospitals (134).

Pressures of Payers—During the 1980s, Medi-care and other health care payers implemented costcontainment measures that increased incentives forhospitals to discharge patients quickly. Medicarealso intensified sanctions by Peer Review Organiza-tions (PROS) for admissions deemed unnecessary(486). PRO efforts and other factors (e.g., changes inmedical practice) are thought to have restricted‘‘social admissions’ of patients admitted to or

allowed to stay in an acute-care setting who do notrequire an acute level of care. The effect of such


having available some care of questionable qualityand having no care available at all. Possible reme-dies for this predicament include: 1) voluntaryregionalization of services to consolidate lowervolume services and improve quality, and 2) selec-

tive contracting whereby payers stipulate that bene-ficiaries use only certain facilities for specific kindsof care.

Hospital Outpatient Utilization

and Ambulatory Surgery

The number and volume of hospital servicesprovided in outpatient settings increased rapidly in



Photo credit: Gad Mooney

Small rural hospitals unable to support full-time physicianspecialists must often rely on itinerant physicians.

Dr. Littleton, a radiologist, travels as needed tohospitals in 12 States.

factors on rural hospital utilization has not beenstudied.

Lower utilization is believed to affect the qualityof certain inpatient services. Studies of varioussurgical procedures (e.g., total hip replacement)have found that worse outcomes tend to occur atlower volumes (495,620). Referral of patients need-ing such procedures to larger hospitals maybe botheconomical and quality-enhancing.

Many small rural hospitals, unable to provide asufficient volume of surgery to support a regularphysician, employ itinerant surgeons (surgeons whotravel to hospitals to operate on scheduled elective

patients and typically are unavailable for followupcare). A recent study of such hospitals found that theuse of itinerant surgery may contribute to higherrates of poor quality care. In the 28 percent of smallrural hospitals sampled that used itinerant surgeons,16 percent of the cases treated by these surgeons hadadverse outcomes (695). In such situations, thereappears to be a tradeoff for the patient between

provided in outpatient settings increased rapidly in

the 1980s, and the growth of outpatient visits wasactually greater for rural than urban hospitals (table5-11). From 1984 to 1988, total outpatient visits torural hospitals increased by over one-third, andoutpatient visits to the emergency room rose nearly13 percent (35).

The increasing demand for outpatient care isreflected in the growth of new outpatient depart-

ments in many rural hospitals. From 1982 to 1985,the number of rural hospital outpatient departmentsrose 48 percent (31). By 1987, 60 percent of ruralcommunity hospitals had outpatient departments(625). As table 5-12 shows, the likelihood that ruralhospitals have outpatient departments increases withthe size of the hospital. Frontier hospitals are lesslikely and rural referral centers are more likely tohave outpatient departments.

10

The amount of surgery performed on hospitaloutpatients has increased dramatically in recentyears. In 1984, about 28 percent of all surgeries inurban hospitals and 26 percent of rural hospitalsurgeries were performed on an ambulatory basis(table 5-11). By 1988, outpatient surgery accountedfor one-half of total surgeries in rural hospitals andover 46 percent in urban hospitals (35). The numberof hospitals providing ambulatory surgery has also

grown rapidly. In 1980, only 65 percent of allcommunity hospitals (rural and urban) performedambulatory surgery (490). By 1987, 93 percent of rural hospitals provided ambulatory surgery (table5-12). Larger hospitals are more likely to offerambulatory surgery; nearly all rural hospitals with200 or more beds provided this service, comparedwith only 77 percent of hospitals with fewer than 25

l~e pwcen~ge of hospi~s tith outpatient dep~ents underrepresents the total number of hospitals actually delive@ outpatient s~i~. Mosthospitals typically provide a substantial portion of nonurgent care in their emergency rooms.





Table 5-13—Number of Federally Funded Community Health Center (CHC) Grantees and Service Sites by Rural/Urban Status andRegion, 1984-88a

Percent change

1984 1985 1986 1987 1988 1984-88

Centers Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban

Grantees

Regionb

I . . . . . . . . . . . . 16 22 15 22 13 24 12 24 12 24 -25 9

II . . . . . . . . . . . . 24 43 24 43 23 44 22 40 20 35 -17 -19

III . . . . . . . . . . . . 65 25 63 24 62 23 54 23 52 22 -20 -12

IV . . . . . . . . . . . . 140 31 141 31 127 34 110 33 104 33 -26 6

v . . . . . . . . . . . . 39 26 37 27 35 28 33 27 31 27 -21 4

VI . . . . . . . . . . . . 37 15 34 16 40 17 37 17 38 17 3 13

VII . . . . . . . . . . . . 12 11 10 11 9 11 6 12 6 12 -50 9

VIII 24 7 25 7 26 8 21 7 20 7 17 0



VIII . . . . . . . . . . . . 24 7 25 7 26 8 21 7 20 7 -17 0

IX . . . . . . . . . . . . 26 22 26 21 29 22 30 24 30 23 15 5x . . . . . . . . . . . . 16 7 16 7 18 7 16 7 16 7 0 0

Total . . . . . . . . . . . . . . . . 399 209 391 209 382 218 329 214 319 207 -20 -1

Total service sitesc

. . . 763 433 791 402 838 464 821 428 793 417 4 -4

NOTE: Definitions used by U.S. Department of Health and Human Services regional offices to identify CHCS as rural and urban approximate

a center’s location in either a nonmetropolitan or metropolitan area.

aFederal Fiscal years.

bFederal Department of Health and Human Services ‘e6ions. See app. F for geographic display of regions.cTotal rider of Co-nlty Health Center (CHC) service sites includes the number of Federal grantees and permanent federally supported

satellite clinics. They are not intended to include administrative sites where no clinic services are provided or specialty clinics

operating under the same roof as other clinics. Grantees may have more than one service site. Total service site data for 1984 and

1985 may be inaccurate; reporting by grantees improved beginning in 1986 with the use of standard definitions (see text).

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Care Delivery andAssistance, Rockville, MD, unpublished data for rural community health centers 1984-88 from the BCRR file, provided by E.

Sullivan, 1989. E. Sullivan, Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S.

Department of Health and Human Services, Rockville, MD, OTA personal ccmsnunication, April 1990.




Table 5-14-Utilization of Rural Federally Funded Community Health Center Grantees and Service Sites, 1984-88

Percent changeUtilization 1984 1985 1986 1987 1988 1984-88

Total patient encounters.

. . . 9,315,177 9,484,803 10,056,534 10,798,460 11,041,636 18.5

Number of rural

CHC grantees. . . . . . . . . . . . . . . 399 391 382 329 319 -20.0

Average patient encounters

per rural CHC grantee. . . . . . 23,346 24,258 26,326 32,822 34,613 48.3

Number of rural

CHC service sitesb

. . . . . . . . . 763 791 838 821 793 3.9

Average patient encounters per rural CHC service site.. 12,209 11,191 12,001 13,153 13,924 14.0



NOTE: Definitions used by U.S. Department of Health and Human Services regional offices to identify CHCS asrural approximate a center’s location in a ncmmetropolitan area.

aIncludes encounters both on and off the center ‘ite.

bThe total number of rural CHC service sites includes Federal grantees and Permanent federally suPPorted

satellite clinics.They are not intended to include administrative sites where no clinic services are provided, or speciality clinics operating under the same roof as other clinics.Grantees may have more thanone service site. Total service site data for 1984 and 1985 may be inaccurate; reporting by grantees

improved beginning in 1986 with the use of standard definitions (see text).

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of

Health Care Delivery and Assistance, Rockville, MD, unpublished 1984-88 data for rural comnunity

health centers from the BCRR file, provided by E. Sullivan, 1989; E. Sullivan, Bureau of Health Care

Delivery and Assistance, U.S. Department of Health and Human Services, personal communication, April1990.

Table 5-15--PrimaryCare Physician Utilization in Rural Federally Funded Community Health Centersby Region, 1984-88

Regiona

PercentPatient encounters per primary care physician change

1984 1985 1986 1987 1988 1984-88

I . . . . . . . . . . . . . . 3,880II. . . . . . . . . . . . . 5,479III. . . . . . . . . . . . 4,270

IV. . . . . . . . . . . . . 4,486v . . . . . . . . . . . . . . 4,531

VI. . . . . . . . . . . . . 4,540 VII. . . . . . . . . . . . 4,281

VIII. . . . . . . . . . . 4,378

IX. . . . . . . . . . . . . 4,188x . . . . . . . . . . . . . . 3,655

Total . . . . . . . . 4,532

3,7335,537

4,361

4,308

4,406

4,5664,486

3,5994,083

3,716

4,456

3,8575,5824,352

4,153

4,273

4,3964,155

3,8794,193

3,648

4,384

3,9515,189

4,345

4,012

4,338

4,262

3,997

3,982

4,408

3,241

4,283

3,8294,905

4,534

4,227

4,490

4,412

4,280

3,866

4,774

3,810

4,431

-1.3-10.5

6.2

-5.8

-0.1

-2.8

0

-11.714.0

4.2

-2.2

NOTE: Definitions used by U.S. Department of Health and Human Services regional offices to identify CHCS asrural approximate a center’s location in a nonmetropolitan area.

aFederal Department of Health and Human Services regions. See app. F for geographic display of regions.

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau ofHealth Care Delivery and Assistance, Rockville, MD, unpublished 1984-88 data for rural comnunity

health centers from the BCRR file, provided by E. Sullivan, 1989.

over 800 rural health clinics since 1978, but nearly Independent or freestanding clinics account for

one-half have withdrawn from the program forabout 95 percent of all RHCs. Only 25 RHCs are

various reasons, including concerns over RHC provider-based clinics (i.e., sponsored by a hospital,

regulations (see ch. 7)(588). nursing home, or home health agency) (653a).




Figure 5-4-Certified Rural Health Clinics, 1988 (by nonmetropolitan MUA or HMSA county status)



Presence of certified rural health clinics &

NonmetropolitanMedically Underserved Area (MUA) or Health Manpower Shortage Area (HMSA) without certified rural health clinic

_ Nonmetropolitan Medically UnderservedArea (MUA) or Health Manpower Shortage Area HMSA) with certified rural health clinic

_ Nonmetropolitan Non Medically UnderservedArea (MUA) and Non Health Manpower Shortage Area HMSA)

0 Metropolitan county

SOURCE: T.C. Ricketts, Rural Health Research Center, University of North Carolina at Chapel Hill, NC. Analysis of unpublished Area Resource File data(provided by the U.S. Health Resources and Services Administration) conducted under contract with the Office of Technology Assessment, 1989and 1990.

HEALTH MAINTENANCE

ORGANIZATIONS

Health maintenance organizations (HMOs) pro-vide a specified, often comprehensive set of servicesto an enrolled population on a prepaid basis. HMOs

in rural areas showed substantial growth in the early1980s. As of June 1984, there were 118 HMOsserving rural areas in 34 States, and 19 of these werebased in rural areas. This was a substantial increaseover the 79 HMOs serving rural areas in 1981. Thenumber of rural residents estimated to be served byHMOs in 1984 was approximately 500,000, or about1.7 percent of the total rural population (127).

More recently, the number of HMOs nationwidehas declined slightly; 6.6 percent fewer HMOs

-.

existed in 1988 than in 1987 (491). No informationis available on recent trends for HMOs serving ruralareas, but it is unlikely that the overall presence of HMOs in rural areas has increased. Possible reasonsfor the small rural HMO presence include:

q

q

q

q

limited prospects for enrollment due to the

relatively low number of large employers inmany rural areas,

continued resistance of some rural physiciansto participation in HMOs,

lack of available capital for development (Fed-eral funds for HMO development have ceased),

and

concerns of rural HMOs serving Medicare

patients about the adequacy of Medicare pay-ments and how they are calculated.




Table 5-18-Aggregate Uncompensated Care in Community Hospitalsa by Hospital Location and Bed Size, 1984-87

PercentUncompensated care(millions of dollars ) change

Hospital 1984 1985 1986 1987 1984-87

Metro. . . . . . . . . . . . . . . . . . . . . $8,377 $8,301 $10,320 $11,174 33.4

Nonmetro. . . . . . . . . . . . . . . . . . 1,162 1,225 1,344 1,468 26.36-24 beds. . . . . . . . . . . . . . . 8 9 11 13 59.025-49. . . . . . . . . . . . . . . . . . . 107 116 141 145 35.550-99. . . . . . . . . . . . . . . . . . . 294 314 353 376 27.9100-199. . . . . . . . . . . . . . . . . 425 454 485 507 19.3

200-299. . . . . . . . . . . . . . . . . 185 196 223 255 37.8300 or more . . . . . . . . . . . . 143 135 131 171 19.6

NOTE: Uncompensated care costs include deductions from hospital revenue attributable to bad debt and charity

care.



acomunity hospitals defined as all non-Federal, short-term general and other special service hospitals.

SOURCE: American Hospital Association, Chicago, IL, unpublished data from the Annual Survey of Hospitals,

1984-87.

high rural concentration of elderly residents, whotypically are less mobile and may be more likelythan other rural residents to receive care at the localhospital. Medicaid revenues, on the other hand, are

a slightly lower percentage of total patient revenuesin rural than in urban hospitals (8.7 percent v. 9.6percent in 1986) (table 5-19). This is not necessarilya positive factor for rural hospitals however; poorrural residents are less likely than poor urban ones tobe eligible for Medicaid (see ch. 2), and fewerMedicaid patients may mean more charity pa-tients.

18

Rural hospitals increasingly depend on State andlocal tax subsidies. Table 5-21 shows that in 1987,69 percent of rural community hospitals receivednon-Federal tax appropriations worth over $216million. The average tax appropriation per hospitaldoubled from 1984 to 1987. Very large ruralhospitals receive the largest State and local subsi-dies, with the smallest hospitals a somewhat distants e c o n d .

Many of the health care dollars that might helpsupport rural hospitals are spent outside the commu-nity. A study of 3 rural communities in Washington,each with a hospital of 50 or fewer beds, found thatabout one-half the residents’ expenditures for carewere not spent in those communities. In 1985, thetotal expenditures for health services by residents in

the three communities was just under $31 million;the revenues needed to support the communities’local health care services was approximately $14.5million, of which 62 percent was for the hospital

(46).

Difficulties in Shifting Costs

Faced with providing uncompensated care, ahealth facility has three options to cover the loss:

q

q

q

private or public subsidy (e.g. charitable dona-tions),recouping sufficient extra revenue from paying

patients, orinternal cross-subsidy from other profitableactivities and investments.

Rural hospitals are at a particular disadvantage intrying to realize additional reimbursement, becausetheir small size makes it difficult to spread costs tolarge numbers of paying patients. Hospitals with ahigh proportion of Medicare and Medicaid patientshave additional problems with cost-shifting, sincethese sources of payment are relatively inflexible.

A recent study in Wisconsin found that 18 to 35percent of charges by rural Wisconsin hospitals toprivate-pay patients were required to cover revenueshortfalls from Medicare, Medicaid, and charitycare. The smaller hospitals (with an average daily

18~mnY s~tes, Medicaid payment levels for hospital and physictin -e r ernain signifkantly below provider costs or charges for such cw e (see ch.3).






Table 5-23-Hospital PPS Operating Margins for the First 5 Years of PPS, by Hospital Location and Type

Percentage of hospitals

ual oDor ating ~ns (twrccnt ) q with 4 years of

PPS PPS PPS PPS PPS negative margins inHospital type

b

1 2 3 4 5 first 5 years

Metro. . . . . . . . . . . . . . . . . . . . . . . 15.8 15.5 11.3 6.8 3.6 3.2

Nonmetro. . . . . . . . . . . . . . . . . . . . 8.4 8.8 3.1 -0.3 -2.3 10.7

Und@r 50 beds. ...:..... . . . 6.4 6.0 -0.9 -2.3 -3.5 11.950-99. . . . . . . . . . . . . . . . . . . . . 8.4 7.4 1.4 -1.6 -4.0 11.3100-169. . . . . . . . . . . . . . . . . . . 8.8 8.1 3.0 -0.7 -0.5 7.5170 beds and over. . . . . . . . . 9.4 12.4 6.9 2.4 -1.8 6.9

Rural referral . . . . . . . . . . . . . . 9.5 13.4 8.2 4.3 -0.1 3.5

Sole c Cslsnunity. . . . . . . . . . . . . . 6.9 6.2 1.2 -2.7 -4.2 13.2

Other nonmetro. . . . . . . . . . . . . . 8.0 6.5 0.3 -2.8 -3.4 11.1

NOTE: stands for Medicare’s prospective payment system i M l d d N J



NOTE: PPS stands for Medicare’s prospective payment system. Hospitala in Maryland and New Jersey areexcluded; hospitals in Massachusetts and New York are included beginning in PPS 3.

apps l-pps 5 roughly corresponds to Federal fiscal years 1984-

88.b

A1l pps hospitals.

SOURCE: Prospective Payment Assessment Commission, Medicare Prospective Paw ent and the American Health Care

System: Report to Congress (Washington, DC: U.S. Government Printing Office, June 1990).

Table 5-24-Fifth-Year Hospital PPS Operating Margins: Means and Percentiles by Hospital Location and Type

Mean 1Oth 50th 90thHospital type

a

percent percentile percentile percentile

All hospitals. . . . . . . . . . . . . . .

Metro . . . . . . . . . . . . . . . . . . . . . . .

Nonmetro. . . . . . . . . . . . . . . . . . . .

Under 50 beds. . . . . . . . . . . . .

50-99. . . . . . . . . . . . . . . . . . . . .

100-169. . . . . . . . . . . . . . . . . . .

170 beds and over. . . . . . . . .

Rural referral. . . . . . . . . . . . . .

Sole community. . . . . . . . . . . . . .Other nonmetro. . . . . . . . . . . . . .

2.6

3.6

-2.3

-3.5

-4.0

-0.5

-1.8

-0.1

-4.2

-3.4

-28.3

-22.2

-33.9

-48.5

-28.2

-28.2

-16.8

-14.8

-45.0

-35.2

-0.5

1.2

-2.6-2.4

-3.2

-1.8

-1.7

1.1

-6.3

-2.6

18.6

19.7

17.2

20.4

14.0

13.3

14.8

15.5

14.5

18.0

NOTE: PPS stands for Medicare’s prospective payment system. Hospitals in Maryland and New Jersey are ex-

cluded. The fifth year PPS roughly corresponds to Federal fiscal year 1988.

aAll PP S hospitals.

SOURCE: Prospective Payment Assessment Commission, Medicare Prospective Payment and the American Health CareSystem: Report to Congress (Washington, DC: U.S. Government Printing Office, June 1990).

Medicare days have shown poorer Medicare mar-

gins since the beginning of PPS (492).

Ambulatory Surgery and Medicare Payment

Rural hospitals have found revenue from outpa-tient services increasingly important to their sur-vival. In 1987, over 23 percent of all gross patientrevenue in rural hospitals was from outpatientservices; this proportion represents an increase of more than 50 percent since 1984 (table 5-25).

Smaller rural hospitals had the greatest dependenceon outpatient revenue. By comparison, less than 19

percent of patient revenue in urban hospitals was

from outpatient sources (30).

Medicare payment for ambulatory surgery can bea major source of outpatient revenue. CurrentMedicare payment for hospital outpatient surgery isbased on the lesser of reasonable costs or a blend of hospital costs and freestanding ambulatory surgerycenter (ASC) rates. Freestanding ASCs currentlyreceive lower payment rates from Medicare, and

they reportedly have lower fixed costs than dohospitals. A recent analysis found that hospital

Chapter 5-Problems and Trends in Rural Health Services q 135

Table 5-25-Community Hospitals:a Gross OutpatientRevenue From Outpatients as a Percent of Total GrossPatient Revenue, by Hospital Location and Bed Size,

1984 and 1987

1984 1987

Metro hospitals. . . . . . . . . 14.1 18.5

Nonmetro hospitals. . . . . . 15.3 23.5

6-24 beds. . . . . . . . . . . . . 20.7 34.3

25-49. . . . . . . . . . . . . . . . . 17.2 27.6

50-99. . . . . . . . . . . . . . . . . 16.1 25.5

100-199. . . . . . . . . . . . . . . 15.2 23.5

200-299. . . . . . . . . . . . . . . 14.3 20.7

300-399. . . . . . . . . . . . . . . 14.1 18.5

400-499. . . . . . . . . . . . . . . 12.8 18.1

500 or more . . . . . . . . . . 9.1 13.9

NOTE: Gross patient revenue consists of revenue

q

q

q

ASCs may ’’skim’’ the least-complicated casesand better-paying patients, leaving competinghospitals with the more complex and uncom-pensated cases.At least 85 percent of ASCs are located in urban

areas (99). ASCs can generate low coststhrough specializing in high-volume services.Rural hospitals, on the other hand, generallyhave low surgical volumes due to low popula-tion density in their service areas.Hospitals generally provide a wider range of needed services than do ASCs, including morenonroutine care and standby capacity for emer-gencies that result in higher fixed costs. Other

requirements associated with the need to ac-commodate intensive care in hospitals (higher



NOTE: Gross patient revenue consists of revenue

based on full established rates from services

rendered to patients, including payments

received from or on behalf of individual

patients.

acowunity hospitals defined here as all non-Federal,


tals.

SOURCE: American Hospital Association, Chicago, IL,

unpublished data from Annual Survey of Hos-

pitals, 1984-87.

outpatient surgery costs are significantly greaterthan the current blended payment rate (table 5-26)(490). Hospitals reimbursed under the blended ratereceive payments that are 19 percent lower than theirper-case costs.

23

Medicare expenses for outpatient care have in-

creased dramatically in recent years, and Congresshas directed that a prospective payment system bedeveloped for such care (see ch. 3). A danger existsthat more stringent outpatient payment controlscould further increase the risk of survival for manyrural hospitals. A 1989 study found that if proposedper-case payment rates to ASCs were applied to ruralhospitals, they would be 38 percent less thanhospital costs (table 5-26) (490). Outpatient surgerycosts for a hospital service may be greater than ASCcosts for that service for a number of reasons:

. Most hospitals, in an effort to lower inpatientcosts under PPS, have allocated portions of inpatient care and overhead expenses to outpa-tient services, whose cost thus becomes over-stated.

requirements associated with the need to accommodate intensive care in hospitals (highercosts of skilled staff and supplies) may also addto cost differences between hospitals and ASCs.

Incentives for rural hospitals to provide moreefficient outpatient care may well be appropriate. Apayment system that assumes that rural hospitals canachieve the high-volume efficiencies of ASCs,however, will probably be insufficient to cover costs

and may further threaten hospital survival.

Costs and Operating Margins

Fed by rising amounts of uncompensated care andinflexible or inadequate reimbursement from publicpayers, total expenditures of rural hospitals havebeen growing faster than total revenues. From 1984to 1987, total expenses for rural hospitals rose by15.8 percent, while revenues increased by only 14.4percent (table 5-27). The smallest rural hospitalsexperienced the largest shortfalls; total expenses forhospitals with fewer than 25 beds increased by 28.5percent, while total revenues rose by only 21.9percent (30).

By 1987, the smallest rural hospitals also had thehighest total expenses per inpatient day-$724 for

hospitals with fewer than 25 beds, compared with$534 for all rural hospitals (table 5-28) (625). SmallSCHs and frontier hospitals had especially highexpenses per day, suggesting that the very smallestand most isolated rural hospitals have the greatestdifficulty providing a sufficient volume of servicesto cover their freed expenses. Expenses also in-creased with size for very large hospitals, possiblyreflecting the delivery of more complex care. For

23~e ~~y~is did not awomt for any improvements ~ hospi~ efflcieng brought a~ut by refo~ under M@care’s prospective payment SyStem.

Table 5-26--Mean Hospital Costs Per Case Compared With Mean Proposed ASC Payments Per Case and Blended Rate Payments Per Case,by Hospital Location and Bed Size

Percent (A) (B) (c) Difference between Difference betweenof total Facility Proposed Blended columns (A) and (B) columns (A) and (C)

Hospital ASC-approved costs ASC payment rate payment costs per case costs per casetype surgical cases per case

a

per caseb

per casec

dollars percent dollars percent

All. . . . . . . . . . . . . . . . . . 100 $640 $394 $517 -.$246 -38 -$123 -19

Metro . . . . . . . . . . . . . . . . 81 675 414 545 -261 -39 -130 -19

Nonmetro. . . . . . . . . . . . . 19 580 361 471 -219 -38 -110 -19

Under 50 beds . . . . . . . 2 551 338 445 -213 -39 -107 -1950-99. . . . . . . . . . . . . . . 5 592 360 476 -232 -39 -116 -20



50 99. . . . . . . . . . . . . . . 5 592 360 476 232 39 116 20

100-169. . . . . . . . . . . . . 6 611 379 495 -231 -38 -116 -19

170 beds and over... 6 563 386 474 -176 -31 -88 -16

NOTE: ASC stands for ambulatory surgery center. Cost and payment estimates based on outpatient department surgical bills from October

1, 1987 through June 30, 1988.

aThe u s Health Care Financing Administration estimated costs for each bill by applying hospital-specific departmental cost-to-char6e. .

ratios from the Medicare Cost Report to charges on the outpatient department bill.bASC payment per case is adjusted to reflect area wage indices.

c

The blended rate payment e~als 50 percent facility Costs phlS 50 perCeIlt. proposed Asc Payment.

SOURCE: Prospective Payment Assessment Commission, Medicare Paym ent for Hospital Outpatient Surger Y: The Views of the Prospective

Payment Assessment Commission (Washington, DC: U.S. Government Printing Office, April 1989).




Table 5-28-Total Mean Expenses Per Inpatient Day for Nonmetropolitan Community Hospitals a by Bed Size, 1987

Nonmetropolitan Sole community Hospitals in Rural referral

Bed size hospitals hospitals frontier areas centers

6-24 .. .. .., .. .. ... ... ...$724

25-49. . . . . . . . . . . . . . . . . . . 585

50-99. . . . . . . . . . . . . . . . . . . 494

100-199. . . . . . . . . . . . . . . . . 466

200-299. . . . . . . . . . . . . . . . . 482

300-399. . . . . . . . . . . . . . . . . 517

400-499. . . . . . . . . . . . . . . . . 519

500 or more. . . . . . . . . . . . . 566

$948 $903

686 535 $2;:

572 277 681

560 260 633

473 87 551

518 NA 513

429 NA 495

NA NA 584

Total . . . . . . . . . . . . . . ...$534 $651 $518 $588

NOTE: NA = not applicable.

acomunity hospitals defined here as all non-Federal, short–stay,b

nonspecialty hospitals (see app. C).As defined for Medicare purposes (see C).



As defined for Medicare purposes (see app. C).


Survey of Hospitals.

Table 5-29--Total Expenses Per Nonmetropolitan Community Hospital’ by Ownership and Bed Size, 1987

Type of Ownership

Government Nonprofit For-profit

Mean expense Mean expense Mean expenseBed size Number per hospitalb

Number per hospitalb

Number per hospitalb

6-24. . . . . . . . . . . . . . . . . . 118 $1,262 66 $1,478 16 $1,556

25-49. . . . . . . . . . . . . . . . . 423 2,474 324 3,087 70 2,825

50-99. . . . . . . . . . . . . . . . . 362 5,164 432 6,448 99 6,258

100-199. . . . . . . . . . . . . . . 165 10,787 305 14,087 69 21,080

200-299. . . . . . . . . . . . . . . 23 25,113 102 25,874 10 22,932

300 or more. . . . . . . . . . . 7 47,847 30 $51,378 NA NA

----------------------------------------------------------------------------------------------------------

Total . . . . . . . . . ......1,098 $5,243 1,259 $9,818 264 $7,216


acomunity hospitals defined here as all non–Federal, short–stay, nonspecialty hospitals (see app. C).b

In thousands of dollars.



to help fund such projects. Therefore, outside capitalis often needed.

The sources of outside funding for capital projectsin rural hospitals have changed over the years. Untilthe early 1970s, hospitals derived most of theircapital for major purposes from Hill-Burton con-struction grants and charitable contributions. TheHill-Burton grant program ended at a time whencharitable contributions as a proportion of capitalfunds were also declining. However, commercial

loan programs under Section 242 of the Federal

Housing Act developed in the 1970s, enabling

nonprofit hospitals to dramatically improve theiraccess to capital financing for construction and

renovation projects. The creation of the Medicareand Medicaid payment programs in the 1960s alsoallowed hospitals to be reimbursed a share of reasonable capital costs (primarily interest and

depreciation) related to the institutions’ Medicareand Medicaid patient load.

25Since 1986, however,

~~somes~tes, Medicaid does notpayhospiMs for capital inthe same way as Medicare (474).




been a popular source of low-cost funds for non-profit rural hospitals, CHCs, and other health carefacilities, although its application review process isoften criticized as being slow and cumbersome(251). Rural hospitals have relied heavily on local

banks for capital funding, but their often higherinterest rates and tightening credit restrictions havemade many less competitive with urban banks. Also,according to a 1989 survey, 18 States have estab-lished financing programs to make capital fundsavailable to nonprofit hospitals and other facilities;at least 2 State programs focus on the particularcapital needs of rural facilities. These programs’funds, however, are often narrowly restricted, andhospitals with poor credit ratings may have diffi-culty qualifying (474).

Table 5-32-Community HospitalsaAcquiring NewCapital Debts, by Hospital Location and Bed Size,

1984 and 1987

1984 1987

Percent Percent

Hospital Number of total Number of total

Metro. . . . . . . . . . . . 565

Nonmetro. . . . . . . . . 342

6-24 beds. . . . . . . 11

25-49 . . . . . . . . . . . 84

50-99 . . . . . . . . . . . 114

100-199 . . . . . . . . . 94

200-299 . . . . . . . . . 24

300 or more . . . . 15

18.4

12.7

6.0

10.5

12.2

15.5

18.3

32.6

729

503

23

135

169

122

36

18

24.2

19.4

12.0

16.8

18.9

22.8

26.7

47.4

acomunity hospitals defined here as all non-FederalP


t l



The proportion of rural hospitals obtaining newcapital debt is small but growing (table 5-32). Fewersmall than large rural hospitals obtained new capitaldebt from 1984 to 1987, perhaps because of theinability of small rural hospitals to acquire capitalfinancing (30). This trend might also be explained bythe increasing amounts of unborrowed funding

available to small hospitals for capital projects. Theamount of funds given to hospital endowments andrestricted for facility construction/renovation andother purposes increased significantly for smallerrural hospitals. From 1984 to 1987, such funds rosenearly 59 percent for hospitals with 25 to 50 bedswhile declining 15 percent for hospitals with 100 to199 beds (table 5-33) (30).

FINANCIAL VIABILITY OFCOMMUNITY HEALTH CENTERS

Revenue Issues

Demand for Uncompensated Care

The number of persons receiving discounted orunpaid care in rural CHCs is also growing. A recentsurvey of rural CHCs reported that many CHC userswere paying for services under a sliding fee scale,permitting patients with incomes up to 200 percentof poverty level to pay less than full charge (theexact amount paid is based on income and familysize). In 1987, nearly one-half of all users of surveyed CHCs paid for services according to asliding fee scale (table 5-34). The number of patientsrequiring subsidized service in rural CHCs in 1987ranged from 82 percent of users in Region VI to only7 percent in Region I (307).

tals.

SOURCE : American Hospital Association, Chicago, IL,unpub Ii sh ed data from Annua 1 Survey o f

Hospitals, 1984-1987.

The inability of rural CHCs to recoup the fullcharge is also reflected in the centers’ overallcollection rate. In 1988, just 48 percent of all

charges-whether full or discounted-were col-lected. Regionally, rural CHC collection ratesranged from 82 percent of charges in Region I to just26 percent of charges in Region II (658).

Reliance on Public Paymentand Funding Sources

The proportion of rural CHC revenues that derive

from public payment sources has increased noticea-bly in recent years. In 1984, Medicaid revenues wereabout 19 percent of total patient revenue; by 1988,the proportion had risen to nearly 25 percent (figure5-5). During the same period, the proportion of totalrevenues collected directly from patients fell from44 to 38 percent (658). These trends offer additionalevidence that rural CHCs are serving increasingnumbers of patients who are unable to pay for basic

health care.

Despite overall increases in patient revenues,CHCs remain heavily dependent on governmentgrant funding to cover expenses. Rural CHCs relymore heavily than others on Federal grants as aproportion of total revenue, even though the propor-tion has declined slightly in recent years (table 5-35)(585). Among rural CHCs, frontier CHCs areespecially dependent on Federal funds. For the years

1985 through 1987, 30 frontier centers surveyed in




Figure 5-5-Sources of Payment for Services inRural Federally Funded Community Health Centers,

1984, 1986, and 1988a

Percent‘“~ 43.6 I

30 \

20

10

0I

Medicare Medicaid Other inaurance Direct patient

Source of payment collection

m 1984 = 1986 m 1 9 6 6

t

Table 5-35-Community Health Center (CHC) Revenueand Expenses, 1986 and 1988

Percentchange

1986 1988 1986-88

Number of CHCsRural. . . . . . . . . . . . . . . 382 319 -16.5Total. . . . . . . . . . . . . . . 600 526 -12.3

-----------------------------------------------------

Total operating revenuea

(in millions of dollars)Rural. . . . . . . . . . . . . . . $356 $415 16.5Total. . . . . . . . . . . . . . . $877 $997 13.7

-----------------------------------------------------

Percent Federal grantsof total revenue

Rural. . . . . . . . . . . . . . . 52% 47% -9.6Total. . . . . . . . . . . . . . . 48% 43% -10.4-----------------------------------------------------



NOTE: Total may not equal 100 percent due to rounding.~otal payments were $105 million in 1984,$128 million in 1988, and$161

million in 1988.

SOURCE: Office of Technology Assessment, 1990. Data from U.S.Depa~ent of Health and Human Services, Health Resourcesand Services Administration, Bureau of Health Care Deliveryand Assistance, Rockville, MD, unpublished 1984-88 data forrural community health centers from the BCRR File, provided byE. Sullivan, 1989.

revenue derived from Federal grant funds droppedby nearly 10 percent from 1986 to 1988, and the dropwas barely balanced by the 26 percent increase inpatient revenue for the period (see figure 5-5 andtable 5-35) (585,658).

FACILITY CLOSURES

Facilities that cannot generate sufficient revenue

to maintain their financial viability eventually close.

28

Where alternative sources of care are not easilyavailable, facility closure could severely limit accessto critical services by people living in the commu-nity. Where services are duplicative, on the otherhand, facility closure may actually allow local healthcare resources to be allocated for better use. Thefollowing section describes the trends in ruralfacility closures and their potential consequences for

access to care and general efficiency of the healthdelivery system.

Number of Hospital Closures

Rural community hospital closures totalled 237from 1981 through 1989, with annual numbers risingsteadily for most of that time (figure 5-6). Since1986, more rural than urban hospitals have closed;

Total expenses(in millions of dollars)

Rural. . . . . . . . . . . . . . . $348 $414 19.0

Total. . . . . . . . . . . . . . . $866 $998 15.2

NOTE : Definitions used by U.S. Department of Health

and Human S ervi c es r eg iona 1 0 f f i c es to

identify CHCS as rural or urban approximate a

centers location in either a nonmetropolitan

or metropolitan area.

aTotal operating revenue includes both revenue from

patient charges and nonpati ent revenue such as

Federal grant funds.

SOURCE : E. Sullivan, Bureau of Health Care Delivery

and Ass is t an c e , Health Resources and

Services Administration, U.S. Department of

Health and Human Services, Rockville, MD,

personal conrnunication, January 1989.

in 1989, rural hospital closures represented over

two-thirds of all community hospital closures (328).A recent report predicts that, if these trends were tocontinue, 40 percent (about 2,700) of all U.S.hospitals would close or convert to other health carepurposes by the year 2000 (415). Only three States(Rhode Island, Vermont and Wyoming) and theDistrict of Columbia had no hospitals close between1980 and 1989 (33,116).

Available figures on hospital closures are notalways complete and useful measures of changes inaccess to basic health services. Annual AHA num-bers on community hospital closures include as“closed’ all hospitals that no longer provide acuteinpatient care (as of the end of the year). Some of these hospitals may still have an acute-care license,or they may have remained in operation as a

~There maybe rwons other than f~ncial hardship for the closure of health care facilities (e.g., gOVeMInent [email protected] facflity merge~).








Table 5-39-Changes in Rural Community HealthCenter Grantees: Mergers, Closures, and

New Starts, 1984-88

New Wentb clo~uresc starts

d

Yeara

Mergers privatee

Total

1984. . . . . . 1 14 12 0 27

1985. . . . . . 12 15 7 0 341986. . . . . . 21 31 18 0 70

1987. . . . . . 8 11 11 0 30

1988. . . . . . 2 bf 3 2 11

TOTAL. . . 44 75 51 2 172

NOTE: Definitions used by U.S. Department of Health

and Human Services regional offices to

identify CHCS as rural approximate a center’s

location in a nonmetropolitan area.aFederal fiscal year.bThose merging with another CHC.

or phasing out operations.

489, and no new providers were expected to locatein these towns soon (103).

POPULATION MOBILITY AND

ACCESS TO CARE

Patient Outmigration

Regardless of whether local hospitals or clinicshave closed, many rural residents have alreadydecided to leave their local communities to obtainsome or all needed services. Such action may beeither for the purpose of receiving care locallyunavailable (e.g., highly sophisticated tertiary care),

or because residents choose not to use local services.A few studies have attempted to document this‘‘outmigration’ for hospital services in rural areas.



cThose closing or phasing out operations.

dNew CHCS beginning operations that Year.

eThose choosing to relinquish Federal support and be–

come private.flnc~uding 1 that phased out to become Part of

a

‘Os-

pital.

SOURCE: E. Sullivan, Bureau of Health Care Delivery

and Assistance, Health Resources and Ser-

vices Administration, U.S. Department of

Health and Human Services, Rockville, MD,personal communication, January 1989.

improve center efficiency (585). No information isavailable on the areas where rural CHCs closed, orthe reasons for closure.

A study of nurse practitioner and physicianassistant (NP/PA) satellite centers established in the

1970s suggests that some of the reasons foreclosureof primary care facilities may have changed overtime. In a national sample of 44 rural NP/PA satellitecenters surveyed between 1975 and 1985, 12 hadceased to function, leaving their communities with-out immediate sources of primary care. Of the eightcenters that closed before 1979, reasons given forclosure included poor financial management, deathof the backup physician, relocation of the town’s

major employer, the center’s purchase by a physi-cian who later left the area, and establishment of anew, physician-staffed clinic nearby. The averagepopulation of these communities (in 1980) was1,960, yet by 1984, physician practices had locatedin all of them. For the four centers that closed after1979, however, the major reason given was lowservice utilization. The average local population was

g p

A 1988 study examining the patient travel pat-terns of Medicare beneficiaries in rural areas sug-gests that a significant number of patients relied onout-of-area institutions for inpatient care. The studycompared rural hospitals’ actual share of the numberof Medicare residents in their market area who

obtained care at any hospital. When a very narrowdefinition of a hospital’s market area was used,

3264

percent of all rural hospitals provided at leastone-half of the total inpatient discharges of Medicarepatients residing in their market area. Just 7 percentof rural hospitals (195) provided as much as 75percent of the inpatient care used by Medicarepatients from their narrow market area. When thewidest market area definition was used, rural hospi-

tals’ market shares were smaller; only 46 percent of rural hospitals provided at least one-half of theinpatient discharges of area Medicare patients. Forthe most isolated hospitals-those that were 50miles or more from the nearest hospital or were ofteninaccessible due to seasonal weather conditions—market shares were still surprisingly small. Usingthe widest market definition, fewer than 6 percent of these hospitals delivered as much as 75 percent of the inpatient care of area Medicare beneficiaries(589).

A New York study of travel patterns for inpatientcare by rural residents during 1983 found that 71percent of all hospitalizations of rural residents werein the patients’ own county (table 5-40). The oldestrural residents were the least likely to travel for care;

32~e -owe~t &~tion of ~ ho@~>~ -tit ~= incl~d~ o~y tie ~ codes n~~t me hospi~s and horn which the facilities drew at least50pereent of their Medicare patients. The widest definition included ZIP codes from which the hospital drew at least 75 pereent of its Medicare patients.


Table 5-40-Sources of Inpatient Care forRural Residents in New York State, 1983

Nonmetro

hospitals Nonmetro

Metro out of hospitals,

hospitals county in county

All nonmetro patients:

Percent of discharges. . . 19.3 9.7 70.9

Percent of days. . . . . . . . . 22.3 9.1 68.7

Nonmetro patients

over age 75:

Percent of discharges. . . 10.2 8.0 81.7

SOURCES: M. Merlis, “Rural Hospitals,U

U.S.Congress, Congressional Research Service,

Washington, DC, no. 89-296 EPW, May 1989;

and C. Hogan, “Patterns of Travel forRural Individuals Hospitalized in New York

State: Relationship Between Distance, Des-

ti ti d C Mi ” J l f R l



tination and Case Mix,” Journal of Rural

Health 4(2):29-41, July 1988.

82 percent received care in their home county.Nearly two-thirds of all those who left their owncounty for inpatient care traveled to urban hospitals(265). Rural hospitals in New York have an abnor-

mally high occupancy rate (84 percent in 1983,compared with 66 percent for rural hospitals nation-ally), so these outmigration rates are probably lowerthan would be found in other States (382).

Results of a survey of households in the serviceareas of six rural Washington hospitals likewisesuggest that there are different outmigration patternsfor different segments of the population. In this

study, higher income households with private insur-ance were more likely than other households to leavetheir local community for hospitalization (table5-41)(237).

Of those surveyed that had used a hospital outsidetheir rural community, a large proportion (rangingfrom 41 to 63 percent) stated that the service theyneeded was unavailable in their local hospital. Asimilar proportion of respondents stated that theyhad been referred to the nonlocal hospital either bya local or nonlocal physician. Residents’ use of alocal physician was also associated with increasedlikelihood of using a local facility. When askedwhether they would use the local hospital forspecific medical conditions, respondents indicatedless willingness to use the local hospital for moreapparently complex services. Only one-fourth wouldnot use the local hospital for the care of a broken


Poor road conditions in rural areas can lengthen traveltimes to health care facilities.

arm, but 90 percent would migrate elsewhere forcancer care (237). Similar usage patterns wereobserved in a recent five-State study that found thatmost rural Medicare beneficiaries needing special-ized “high-tech” care traveled to urban hospitals(134).

Geographic Limitations to Access to Care

Time and Distance Between Hospitals

Geographical access to health care remains acritical issue in many rural areas. In one study thatexamined distances and travel times between ruralhospitals, 84 percent of all rural hospitals werewithin 30 road miles of a neighboring hospital (table5-42). Only 86 rural hospitals (3 percent) were morethan 50 road miles from the nearest hospital. The

Mountain region, with its rugged terrain and lowpopulation density, was a clear exception to nationalaverages; fewer than one-half of rural hospitals inthat region were within 30 road miles of the nearestalternative hospital. Of the 39 percent of all ruralhospitals that were the sole hospitals in theircounties, nearly 70 percent were less than 30 roadmiles from the nearest hospital (589).

Travel time is often considered a better indicator

of distance between hospitals than road mileage,


Table 5-41—Household Characteristics for “Community C“ by Hospital Utilization Experience, 1984-85

Hospital Utilization

Local Local and NonlocalHousehold hospital nonlocal hospital Notcharacteristics only hospital only hospitalized Overall

Income $25,000 or more (percent). . . . . . . . . . 21.6 28.2 35.9 24.4 26.3

All members 60 years old or

older (percent). . . . . . . . . . . . . . . . . . . . . . . . . . 26.1 26.5 20.7 24.7 24.5

Private insurance is expected

principal hospital payer (percent)a

. . . . . . 44.3 44.9 55.0 45.4 46.8

Less than 30 minutes from local

hospital (percent)b

. . . . . . . . . . . . . . . . . . . . . . 87.9 91.0 70.5 80.1 80.0

More than 10 years living incommunity (percent). . . . . . . . . . . . . . . . . . . . . . 58.8 57.1 62.2 57.2 58.4

Personal physician status (percent):Local personal physician . . . . . . . . . . . . . . . . 79.9 74.3 34.3 56.8 59.5

Nonlocal personal physician . . . . . . . . . . . . . 11.6 6.6 11.1 22.4 16.4No personal physician . . . . . . . . . . . . . . . . . . . 8.5 19.1 54.5 20.8 24.1--------------------------------------------------------------------------------------------------------------

Number of respondents. . . . . . . . . . . . . . . . . . . . . 228 136 203 596 1,139



(percent of households) ....,.... . . . . . . . . . 2O.O 1 1 . 9 1 7 . 8 5 2 . 3 1 0 0 . 0

NOTE: “Community C“ refers to one of the rural communities in Washington included in a study of rural

hospital utilization.

aResponse is for the respondent but is utilized as a proxy for the household.bData are from ‘co~unity E“.

These data are typical of all the communities except “Comnunity C“ where therewere no meaningful differences.

SOURCE: G. Hart et al., Rural Hospital Utilization: Who Stays and Who Goes?Rural Health Working PaperSeries, 1(2), WAMI Rural Health Research Center, University of Washington School of Medicine

(Seattle, WA: March 1989).

Table 5-42--Regional Differences in Distances From Nonmetropolitan Hospitals to the Nearest Hospital

Road miles to nearest hospitalTotal

Less than 20-29 30-39 40-49 50 or more nonmetroCensus region 20 miles

a

miles miles miles miles hospitals

New England . . . . . . . . . . . . . . . . . . . 49

Mid Atlantic . . . . . . . . . . . . . . . . . . 69

South Atlantic . . . . . . . . . . . . . . . . 225East North Central . . . . . . . . . . . . 263East South Central . . . . . . . . . . . . 233

West North Central . . . . . . . . . . . . 300 West South Central. . . . . . . . . . . . 261 Mountain. . . . . . . . . . . . . . . . . . . . . . 68

Pacific . . . . . . . . . . . . . . . . . . . . . . . 86

21

30

98

78

74

211

148

47

21

8

5

25

18

20

64

35

62

15

4

2

124

2

14

11

33

8

3

0

1

2

0

9

4

50

17

85

106

361

365

329

598

459

260

147

Total . . . . . . . . . . . . . . . ........1,554 728 252 90 86 2,710

NOTE: Distances are approximately those from one hospital to the nearest hospital. Hospitals are thoseincluded in the 1984 American Hospital Association’s Annual Survey of Hospitals.

aIncludes all hospitals less than 15 “crow-fly” miles to the nearest hospital. These hospitals are allassumed to be less than 20 road miles from the nearest hospital.

SOURCE: Systemetrics/McGraw Hill, “Small Isolated Rural Hospitals: Alternative Criteria for Identificationin Comparison with Current Sole Comnunity Hospitals, ” contract report prepared for the ProspectivePayment Assessment Consnission, Washington, DC, June 1988.



150q


Table 5-45-Regional Distribution of Nonmetropolitan Hospitals by Sole Community Hospital (SCH) Status, 1984

Eligible Eligiblecurrent not current All nonmetro

SCH eligibles Current SCH SCH SCH hospitals

Census region Number Percent Number Percent Number Number Number

New England . . . . . . . . . . . . . . 29Mid Atlantic . . . . . . . . . . . . . 17

South Atlantic . . . . . . . . . . . 9East North Central . . . . . . . 31

East South Central . . . . . . . 3

West North Central . . . . . . . 19

West South Central . . . . . . . 10

Mountain . . . . . . . . . . . . . . . . . 71

Pacific . . . . . . . . . . . . . . . . . . 22

Total . . . . . . . . . . . . . . . . . . 21

13.27.3

3.6

15.5

1.8

10.0

5.0

33.6

10.0

100.0

221

1913

1160

241 1 048

308

7.10.3

6.2

4.2

3.6

19.5

7.8

35.7

15.6

100.0

14 NA

251

12

343

12

92

1517

7

26

2

7

7

28

10

119

85106361365

329598

459

260147

2,710


SOURCE: Prospective Payment Assessment Commission, Technical Appendices to the Commission’s March 1988 Report(Washington, DC:U.S. Government Printing Office, 1988).

M t tl d i t d SCH l t d i th i l d f h i l i I d



Most currently designated SCHs are located in theWest.

36The South has relatively few, probably

because its rural hospitals are closer together (seetable 5-44) and are less affected by extreme weatherconditions. As a result, neither eligible noncurrentSCHs appear to serve a significant number of

low-income rural areas (which are predominant inthe South Atlantic and Central regions) (739).

This study also simulated the impact of four majoralternative eligibility criteria. These included:

q

q

q

q

Substituting travel time for road mileage-A40-minute minimum travel time would add 197hospitals unable to meet the current 50-mile

requirement, bringing the total designated SCHsto 408.

Using sole-county provider status as a measureof isolation—Including all community hospi-tals that are the sole provider in the county orare located 25 miles or 40 minutes from anotherhospital would make a total of 1,224 ruralhospitals eligible to be SCHs.

Being located in a low-density frontier county

with 6 or fewer persons per square mile wouldqualify only 4 hospitals.

37

Serving Medicare beneficiaries in medicallyunderserved areas—This criterion is intendedto measure mobility of the population and other

social needs for hospital services. It was testedin only four States.

The study concluded that relatively few rural facili-ties are physically remote from other hospitals,although for other reasons (e.g., differences incommunity need and hospital services) other hospi-tals may also be irreplaceable health care facilities(739).

Some rural community clinics are the sole provid-ers of primary care services to their communities;however, such status has not allowed them anyspecial protection by the Federal Government.Federally supported CHCs, and some rural clinicsthat receive State support in such States as North

Carolina and Oregon, often serve remote communi-ties unable to attract and support full-time physicianpractices or other health care providers. Little isknown about the extent and nature of these solecommunity primary care facilities, or how criticaltheir presence is to preserving access in areasaffected by geographic isolation.

Frontier Areas

People living in frontier areas, where the nearesthealth care facility may be a great distance away, arefaced by special problems of physical access tohealth care. Hospitals in frontier areas tend to besmall in number and capacity, and the supporting

36~ 1987, 102 s- were l~ated ~ ~ntifl ~~, ~ in tie western ~ of the co~try. N~ly 37 percent of all frontier hospitals were designatedSCHS (62S).

37’f’he ~~ti of hospi~s iden~led by~s a~ysis ~ considerably few~ tin the n-r of hospi~ shown to eat by (YIA analyses ill fll)ntier

areas (277 hospitals in areas with 6 or fewer persons per sqme mile) as noted earlier.




Table 5-47-Federally Funded Community HealthCenter Service Sites Located in Frontier Areas

a

by State, 1989

Number of frontierStates health centers

Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

South Dakota. . . . . . . . . . . . . . . . . . . . . . 5b

Montana. . . . . . . . . . . . . . . . . . . . . . . . . . . 4

New Mexico . . . . . . . . . . . . . . . . . . . . . . . . 4

Utah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Washington. . . . . . . . . . . . . . . . . . . . . . . . 3

Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . 2

Wyoming . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Arizona . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

California . . . . . . . . . . . . . . . . . . . . . . . . 1

North Dakota . . . . . . . . . . . . . . . . . . . . . . 1

New York. . . . . . . . . . . . . . . . . . . . . . . . . . 1

Total . . . . . . . . . . . . . . . . . . . . . .......59

By 1988, one-half of all hospital surgery was doneon an outpatient basis; over 90 percent of allhospitals in 1987 performed ambulatory surgery.Also in 1987, of the 25 percent of hospitals that hada separate long-term care unit, long-term care bedsconstituted nearly one-half of total hospital beds.Frontier hospitals as a group had more long-termcare units (40 percent) and less ambulatory surgery(77 percent) than other rural hospitals. Anecdotalinformation indicates that competition is increasingbetween rural and urban providers and locallyamong hospitals, physicians, and other providers.

As inpatient demand has declined, the receipt of revenue has become more of a problem. From 1984

to 1987, uncompensated care delivered by rural

hospitals rose over 26 percent (increasing faster forsmaller facilities), averaging over $0.5 million perhospital in 1987. Average Medicare payments,which makeup over 40 percent of patient revenue



NOTE: Number of community health centers indicate

the total number of center service sites, in-

cluding federally funded grantees.

aFrontier is defined as counties with six or fewer

persons per square mile.blnc.uding 1 site transferred to the Indian Health

Service in December 1989.SOURCE: E. Sullivan, Bureau of Health Care Delivery

and Assistance, Health Resources and Ser-

vices Administration, U.S Department of

Health and Human Services, Rockville, MD,

personal communication, April 1989.

were designated SCHs in 1987; hospitals located infrontier areas represented 11 percent of all ruralhospitals and were smaller than other rural hospitals

(two-thirds had fewer than 50 beds).

From 1984 to 1988, inpatient admissions in ruralhospitals dropped 21 percent (compared with lessthan 8 percent for urban hospitals). By 1987,inpatient occupancy levels were around 50 percent

for all rural hospitals, becoming smaller as hospital size decreased (31 percent for hospitals withunder 25 beds). Hospitals in frontier areas had

significantly fewer admissions and numbers of staff physicians than other similar-sized rural hospitals.

Rural hospitals are providing increased amounts of outpatient and long-term care services. From1984 to 1988, outpatient visits increased about 34percent (compared to 26 percent for urban hospitals).

which makeup over 40 percent of patient revenue,were actually slightly lower than average costs in19874 in rural hospitals. Although they representonly about 9 percent of patient revenue, Medicaidpayments are often significantly below related costs.In addition, as outpatient services (e.g., ambulatory

surgery) have increased, hospitals (especially smallerfacilities) have become more dependent on outpa-tient revenue, leading to concern over proposedfuture changes in payments for these services.

Total expenses have risen faster than total reve-nues (the smallest hospitals show the largest gap),leading to the decline in both patient and totalhospital operating margins. By 1987, nearly all

rural hospitals had negative patient margins; those

with under 50 beds also suffered negative total margins.

Rural Community Health Centers

The number of CHC grantees fell 20 percent from1984 to 1988, varying widely across regions, al-though the number of total CHC service sitesremained relatively unchanged. In 1988, rural grant-

ees made up 61 percent of all CHCs. From 1984 to1988, patient visits to rural CHCs rose nearly 19percent, again showing significant regional differ-ences.

Most of the increase in CHC utilization appears to be for under- and uncompensated care. In 1987,nearly one-half of all CHC users received discounted

%eactualperiod oftime ishospitals’ fourthyearunderMedicare’sprospective payrnentsystern.



Chapter 6

Short- and Long-Term

Strategies for Effective Changeby Rural Providers



by Rural Providers

CONTENTSPage

INTRODUCTION . . . . . . . . ... ... ... ... ... ... .., ,.. .., o.. c, . + ., ., .,,...,. 157SHORT-TERM STRATEGIES . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . ..,.,,. . 157

Local Fundraising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q . . . . . . 157Cost Containment . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....,,+. ..., 158Tougher Billing and Collection Practices . . . . . . . . . . . . . . . . . . . .. ... . + ....... 159Strategic Planning

. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..,++ 159

Marketing and Public Relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160Improved Leadership and Management.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..,,.++ 160

LONGER TERM APPROACHES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161Hospital Conversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162Hospital Diversification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 162Primary Care Facility Diversification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168Hospital Cooperatives

. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Alliances Between Primary Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172Multihospital Systems . . . . . . ..... . . . . . . . ,...,,. .. . . . . . . . ..... ..,..,....,,, , 173Local Hospital Mergers and Agreements . . . . . . . . . . . . . . . . . . . . . . . . .,..,. , .,. 175



, , , , 175Hospital-physician Agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

SUMMARY OF ENDINGS. . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...,.. . . . . . . . . . . . . 177

Boxes130x Page6-A. Example of Local Fundraising . . . . . . . . . . . . . . . . . ., . . . . . . . . . . . 1576-B. Three Examples of Marketing/Public Relations Efforts

. . . . . . . . . . . . . . . ,.,.,,., .. . . . . . . . . . . . . . . . . . . . . . . . . . . 160

6-C. Example of Successful Short-Term Management . . . . . . . . .. . . . .

. . . . . . . . . . . . . . . . . ,,,,..,,. ., 1616-D. Two Examples of Hospital Conversions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 1636-E. Example of Hospital Diversification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1646-F. Example of Hospital Diversification Into Primary Care . . . . . . . . ..,.,,.. ..,,,,.., .,,., 1676-G. Four Examples of Rural Primary Care Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.. . . 168

6-H. Three Examples of Hospital Cooperatives..,,. . .+. . . . . . . . . . . . 1706-I An Example of a Rural-Urban Hospital Alliance

. . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . ,,,.+++. ,..’..+ 173

6-J. Seven Examples of Primary Care Alliances . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . ..,,++*+ ,,, 1746-K. Two Examples of Multihospital Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .++..,,. ,.,++ 175

6-L. Example of a Local Hospital Merger .,. ...,,.,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,,. 176

FigureFigure Page6-1. Number of Medicare-Certified Swing Bed Hospitals, by Census Region and State, 1987,,. 166

TablesTable Page6-1. Community Hospitals With Medicare-Certified Swing Beds, 1987 . . . . . . . . . . . . . . . . . . . . . . 1656-2. Descriptive Characteristics of Rural Hospital Consortia . . . . . . . . . . . . . . . .++...,. ..,.+... . 1716-3. Nonmetropolitan Hospitals Under 300 Beds in Alliances by Bed Size and Ownership,

1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .+..,... .,.*+.** ,...,, 1726-4. Total Expenses per Hospital by Nonmetropolitan Hospitals in Multihospital Systems

and Alliances,1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1726-5. Nonmetropolitan Hospitals Under 300 Beds in Multihospital Systems by Bed Size and

Ownership, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

Chapter 6Short- and Long-Term Strategies for Effective Change

by Rural Providers

INTRODUCTION

The current problems for rural health care facili-ties and services are varied and complex, and theprognosis for rural health care delivery seemsuncertain at best. The difficulties rural hospitalsface, for example, are not limited to immediateconcerns such as declining inpatient demand andincreases in uncompensated care. Rural hospitalsmust also find ways to redirect their services to meet

evolving community needs and changing environ-mental realities. This chapter will discuss ap-proaches rural hospitals and primary care facilitieshave taken to altering or expanding their missions,both in the short term to strengthen operations and

Establishing endowments is another strategy to

raise ongoing funds. For example, Copley Hospital,a 50-bed nonprofit facility in Morrisville, Vermont,in 1988 resolved to raise a $5 million endowment formaintaining the provision of adequate indigent careand helping with its capital needs (186). In additionto providing some financial benefits to local donors,endowments and other planned giving arrangementsmay enhance the hospital’s reputation in the com-munity.

Hospitals are not the only focus of fundraisingefforts in rural communities. South Gilliam County,Oregon for example has created a health district



both in the short term to strengthen operations andcommunity support, and in the longer term torestructure the organization and delivery of services.

SHORT-TERM STRATEGIES

Local Fundraisingl

Local fundraising has historically been a majorsource of capital to finance construction and renova-tion of rural health facilities. By one estimate, 40percent of cash donations garnered through fundrais-ing by rural and urban hospitals in 1988 wereearmarked for construction, renovation and equip-ment purchases (80). A 1989 national survey found

that more than 30 percent of responding individualshad contributed to hospitals or other health careorganizations (rural and urban) within the previous2 years, and the great majority of these were regulardonors (566).

For some hospitals, fundraising is an importantsource of capital for longer term investments. Forothers, however, local donations and philanthropyare needed simply to sustain immediate operations.

There is considerable uncertainty whether hospitalsin severe financial crises have all the necessaryelements to survive effectively beyond the receiptand use of such “bail-out” funds (see box 6-A).Success may be contingent on how well theseresources are spent on planning for and ensuringfuture needs.

Oregon, for example, has created a health districtfund in cooperation with a local foundation to acceptprivate donations for primary health care projects inthe district. Donations may also be earmarked forspecific health needs (e.g., ambulances) (314).

Box 6-A—Example of Local Fundraising

Hall County Hospital, a 42-bed facility in thesmall town of Memphis, Texas, nearly closed in1988. Two of the three physicians on the hospitalstaff had recently ceased practicing, and patientsbegan migrating 90 miles north to Amarillo formost of their care. Significant declines in patientsand revenues could not be offset through local tax

increases because the community was already taxedat the full legal levy to support the hospital. Instead,the town of 3,000 raised about $400,000 to maintainhospital operations. Memphis’ residents had differ-ing opinions on how to address the hospital’sproblem, and many were weary of spending largesums of money on the hospital. The fund drive tosave the hospital appeared to revive and reunite thecommunity. Local school rallies and support frompassing truckers helped to raise the money over 3

months, leaving the hospital about $100,000 shortof the $500,000 needed and the necessity of stillrecruiting two physicians. Local officials acknowl-edged that unless the town could find the twophysicians, the hospital’s survival remains in doubt(79)

0

ILXXXI ~ Suppo I I is ~o~er major source of nonp atient revenue for h ealth care facilities (see ch . 8).

–157–

158q


payment system; the number of FTE employees inrural hospitals dropped by 7.7 percent between 1983and 1985 alone (31). Rural hospitals also increasedtheir use of part-time staff to enhance their staffingflexibility. In recent years, the numbers of FTE staff per hospital have actually increased. Possible rea-

sons for the increase include more severely illpatients, the growth in outpatient care and swing bedservices, and longer lengths of stay (31,462).

A few rural hospitals, however, have continued toimprove staff efficiencies. Some successful strate-gies

q

q

q

include:

planning staff size and workloads according toexpected daily work volume,

emphasizing cross-training and cross-utilizationof employees to do nonclinical tasks,

combining departments (e.g., housekeepingand engineering) to facilitate flexibility in



Photo credit: Gail Mooney

Even the smallest donations can help rural hospitalsstruggling to survive, and fundraisers can reflect a strong

desire by the community to keep their hospital open.

Cost Containment

Excess capacity, small size, and unexpectedvariations in utilization can make cost reductionsdifficult to achieve in many rural hospitals. One

common strategy for lowering costs has been toreduce staff. From 1980 to 1987, rural hospitalsreduced the number of full-time equivalent (FTE)staff by 9 percent, while urban hospital staffingactually increased 14 percent. Both rural and urbanhospitals had a decline in labor costs as a percentageof total costs (382).

Much of the staff reduction took place immedi-

ately after the inception of the Medicare prospective

q

staffing, and

identifying appropriate uses of outside contractservices for both clinical and administrativefunctions (203).

In 1988, for example, the new administrator of a75-bed hospital in Columbus, North Carolina ap-plied some of these strategies to lay off 10 full-timeemployees (a 6 percent reduction in staff). Otherexpenses were reduced and patient fees increased,creating a net income of $735,000 for the hospital in1988, compared to a net loss in 1987 of $358,000(361).

Many community health centers (CHCs) have

also had to find ways to further reduce costs. Asnoted in chapter 5, increased use by patients whocannot pay for care has lowered collections in manyrural CHCs. A recent survey of these centers foundthat most reported lowering operating costs throughimposing personnel hiring freezes and layoffs,eliminating staff education programs, and reducingsupply orders. Some said they were forced toeliminate certain services altogether (e.g., dental and

pharmacy services) (307).

The cuts made by some CHCs to ensure survivalhave been drastic. A CHC in rural Maryland, forexample, was forced into bankruptcy in the early1980s. Facing pressures from some 900 creditors, anew administrator closed three satellite clinics,reduced staff from 100 to 25, and lowered salaries.The center has remained in operation, relying on

State and local grants instead of Federal finding, and

Chapter 6-Short- and Long-Term Strategies for Effective Change by Rural Providers q 159

was due to make its final payment on the $1.4million bankruptcy decision in 1989 (108).

Tougher Billing and Collection Practices

Hospitals appear to be increasingly aware of howimproved billing and collection activity can enhancecritical cash flow. Hospitals and clinics can affectdelays in billing and payment by methods such as:

submitting correct or “clean” claims to third-

party payers in a timely manner, reducing thenumber of improperly submitted claims re-turned to the hospital for reprocessing;

reducing the delay in assigning final diagnosesand completing patient charts;

increasing the number of patients paying theirbill at the time of service; and

reducing the number of patients who incor-

under the scale, and enforcing stronger collectionprocedures on self-pay balances (307).

Strategic Planning

Rural hospitals, particularly small hospitals, may

often view planning either as a luxury or a burden.It is clear now to many rural providers, however, thatthey must find the means to reexamine their mis-sions and roles and improve their capacity to solveproblems.

One example of efforts to improve the ability of rural hospitals to engage in such planning is theWAMI

2Rural Hospital Project at the University of

Washington. With funds from the Kellogg Founda-tion, WAMI recently assisted several rural commu-nities and their hospitals to develop and implementa range of strategic planning activities. In Tonasket,Washington for example the Project worked in



reducing the number of patients who incorrectly do not receive a bill.

In order to streamline the billing and collectionprocess, one rural hospital put a single individual incharge of registration, billing, discharge, and medi-

cal records. Another hospital assigned a staff mem-ber to the task of ensuring that nurse and physiciannotes are properly recorded in advance of patientdischarge. A third hospital trained staff to encouragepayment before patients leave the hospital, resultingin 12 percent of collections made before the patients’discharge (431).

Some hospitals are establishing inhouse collec-

tion agencies in order to collect a higher proportionof bills, eliminate commission costs, and improveaccess to account information. A rural South Caro-lina hospital’s inhouse agency has collected 22percent of its bad debt (about $200,000 a year) thatotherwise was uncollectible. When the hospital usedan outside firm, it recovered only about 10 percentannually, and 40 percent of this amount was lost incommission costs (432).

Some CHCs have also changed their collectionpractices in response to the growing demand for careby the medically indigent. About 42 percent of recently surveyed centers reported that they weremaking changes designed to lower sliding fee useand improve collections. These changes includedincreasing sliding fee scale eligibility and documenta-tion requirements, increasing the minimum fees paid

Washington, for example, the Project worked inpartnership with the community and its 22-bedhospital to determine the area’s major health caresystem problems by doing area demographic pro-files, community need assessments, and reviews of

hospital operations. Tonasket was experiencing adepressed economy, substantial patient outmigra-tion, and persistent physician shortages. The hospi-tal suffered from negative operating margins, thehighest percentage of uncompensated care of anyhospital in Washington, weak management exper-tise, and patient dissatisfaction. The project facili-tated the development of community teams to clarifygoals and establish trust through open communication

and conflict resolution, and to initiate communityleadership and skill building efforts to plan ways tosolve identified problems. Specific plans were madefor the hospital to lower costs, increase revenues,recruit physicians, market and diversify its services,and restructure its board. Within 3 years, NorthValley Hospital began showing income from opera-tions (45).

Some hospital associations have also been em-phasizing support for strategic planning amongsmall and rural hospitals. In North Carolina, thehospital association, with support from a privatefoundation, recently opted to make planning grantsavailable to such facilities. Of the 67 hospitalseligible for participation, 55 were expected toreceive planning grants by the end of the project(276).

Washington,Alask% Montanaj and Idaho.

160q


Box 6-B—Three Examples of Marketing/Public Relations Efforts

Central Plains Regional Hospital—For hospitals in small towns, “word-of-mouth” and improved visibilitycan play critical marketing roles. Central Plains, a 151-bed hospital in Plainview, Texas, recognized that asignificant number of its local residents were migrating to Lubbock, 45 miles away, for hospital services. CentralPlains’ administrator decided to promote the institution’s quality and convenience, especially to senior citizens

unwilling to travel frequently. To do this, he joined local chapters of service organizations and provided space atthe hospital for their regular meetings, started an annual health fair, and provided health programs at senior citizencenters. He also encouraged the local newspaper to print a regular column on hospital services and activities, andhe personally followed up with discharged patients to ask how they enjoyed their hospital stay. He noted that thesemore personalized efforts appeared to have increased the local appeal of Central Plains over the last 3 years (175).

Mercy Medical Center--Other marketing efforts have attempted to expand the awareness of a facility’scapability to a larger geographical area. Mercy Medical Center, in the isolated mountain community of Durango,Colorado (population 15,000), decided in 1987 to become more of a regional hospital. Impetus came from its needto compete with the other hospital in town, a public facility, for patients in an overbedded market. The 100-bedfacility began to promote its 85-physician medical staff, $1.7 million outpatient center, magnetic resonance imager,

trauma center, and high-technology emergency aircraft to 120,000 residents living over 7,500 square miles in 4States. The hospital used advertising to promote the hospital’s expanded services and its picturesque mountainenvironment (24.?).

Harts Health Clinic—CHCs have also used marketing to successfully improve community awareness andincrease access to care A center in the small remote town of Harts West Virginia successfully used feature articles



increase access to care. A center in the small remote town of Harts, West Virginia, successfully used feature articlesand announcements in the local weekly newspaper, open houses, speaking engagements at area civic clubs, andcolorful brochures and banners to communicate the presence of new providers, equipment, and services. Clinicservice utilization noticeably increased, apparently countering earlier community concerns about the lack of personal physician care and the lack of available needed services in the area (251).

Rural CHCs can also benefit from strategic administrator was most commonly charged with theplanning. The Public Health Service provided cate- marketing function, in contrast to urban hospitalsgorical grants to many rural centers in-tie mid-1980sto develop and implement plans to adapt to localchanges and reduced Federal funding (585). Noknown evaluation of the success of these planningefforts has been performed to date.

Marketing and Public Relations

Many rural hospitals have traditionally encoun-tered little competition by other facilities andproviders. These hospitals now increasingly facedeclining inpatient demand, competition for patientsfrom more aggressive rural and urban providers, andpoor community perceptions of the extent and

quality of their services (see ch. 5). The consequenceis a renewed emphasis on marketing and publicrelations by many rural facilities (see box 6-B).

A 1987 study of 476 small or rural hospitals by theAmerican Hospital Association (AHA) found thatabout 60 percent of the institutions were activelyengaged in marketing, with a heavy reliance onimage advertisements in newspapers (244). A re-lated study in 1985 found that the rural hospital’s

where such responsibilities are typically handled bya marketing director. The study also found a lack of understanding of marketing, and its importance, bytrustees and management (166).

Improved Leadership and Management

Rural hospitals often suffer from inexperiencedadministrators and high management turnover. Ac-cording to one report, the administrator turnover ratereached 24 percent in 1986-87 among urban andrural hospitals combined. The hospitals with thehighest turnover have generally been small, and theyare more likely to have experienced higher costs andlower profits and admission rates than other hospi-tals (607). Yet experienced administrators may beunattracted to rural hospitals because of lowersalaries, and thus many rural institutions may haveto accept untested or mediocre administrators (361).CHCs can also suffer if their administrators areinexperienced; such administrators may lack thetime or sophistication to prepare Federal grantapplications and operations reports in a satisfactory









Chapter 6-Short- and Long-Term Strategies for Effective Change by Rural Providersq

165

Table 6-l-Community Hospitals With Medicare-Certified Swing Beds, 1987

Swing bed hospitalsTotal Medicare-certified swing bed hospitals

.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 983

Percent of hospitals in frontier areas that

are Medicare-certified swing bed hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Percent of sole community hospitals b

that are

Medicare-certified swing bed hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Characteristics (per swing bed hospital) Mean number of acute care beds designated as swing beds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17.3

Mean percent of swings beds to total facility beds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39.6

Mean swing bed admissions:number (percent) of total admissions. . . . . . . . . . . . . . . . . . . . . . . . . 47 (6) Mean swing bed inpatient days:number (percent) of total inpatient days. . . . . . . . . . . . . . . . .888 (13)

NOTE: Comnunity hospitals are defined here as all non-Federal, short-stay,onspecialty hospitals (see app.c).

aN~er does not include 19 hospitals that had swing beds but were not Medicare-certified swing bed hospitals.

Number includes only hospitals in nonmetro areas; Federal law defining geographical eligibility for Medicare

swing bed certification uses the U.S. b Bureau of the Census definition of a rural area. As defined for Medicare purposes.c

Total facility beds include all beds--hospital and long-term care beds.

SOURCE: Office of Technology Assessment, 1990.Data from American Hospital Association’s 1987 Annual Surveyof Hospitals.



Hospitals converting acute-care beds to swing

beds may face problems such as:

staff reluctance to accept new responsibilities;

staff recruitment difficulties imposed by Medi-care’s conditions of participation that requirethe provision of certain services (e.g., recrea-tional therapy);unfamiliarity with regulations that were de-signed for skilled nursing facilities; andinadequate third-party reimbursement.

Most of these problems diminish with hospitalexperience as a swing bed provider (700).

Recent legislative changes (Public Law 100-203)enable all rural hospitals with under 100 beds toparticipate in the Medicare swing bed program

7, thus

expanding the pool of eligible hospitals to about2,800 (555). Hospitals with more than 49 beds mustmeet conditions intended to minimize competitionwith nursing homes. These conditions include trans-ferring extended-care patients within 5 days to a

skilled nursing bed in the hospital’s region unless thetransfer is not deemed medically appropriate by aphysician or there is no such bed available.

In 1987, 983 hospitals were reported to becertified by Medicare as swing bed providers (table6-l). In these hospitals, swing beds accounted fornearly 40 percent of total beds and 13 percent of totalinpatient days. Hospitals located in frontier areas

find swing beds especially attractive. Swing bedhospitals are most prevalent in the central andwestern parts of the United States; the West NorthCentral region contains 42 percent of all swing bed

facilities (figure 6-1).

The growth of swing bed use in some Statesmanbe hampered by certain Federal and State regulations(see ch. 7) however, some States have easedrestrictions on swing bed development. North Caro-lina now exempts swing beds from certificate-of-need review unless expenditures related to swingbeds are $2 million or more, which is unlikely given

the small capital costs required for such diversifica-tion (474). Montana, which previously had allowedMedicaid payment for swing beds only when therewas no available nursing home bed within a100-mile radius of the swing bed hospital, reducedits limit in 1989 to a 25-mile radius (452). Also,several States recently have passed laws authorizingMedicaid to pay for swing bed services. A 1989survey found that 31 States were presently providing

Medicaid coverage of swing bed care (474).

Ambulatory Care

Although nearly all rural hospitals provide someoutpatient services (see ch. 5), ambulatory carecontinues to be an attractive area of hospitaldiversification. In 1987, about 80 percent of allhospitals (both rural and urban) surveyed by the

TS~ te s~soWy extend Medicaid coverage to all rural hospitals under l~beds.


Figure 6-l—Number of Medicare-Certified Swing Bed Hospitals, by Census Region and State, 1987

Pacific Mountain West East

North CentralNorth Central England

IN D

I \

CA

1

Middle

Atlantic

VT---

New

NH

MA

RI

CT

D.C.



\

I

EastWest SouthSouth Central Central

. Regional totals.

I South Atlantic

sWest North Central 415 s South Atlantic 68sWest South Central 133 sPacific 42sMountain 124 sNew England 13sEast South Central 98 sMid-Atlantic 3s East North Central 87

SOURCE: Office of Technology Assessment, 1990. Data from American Hospital Association’s 1987 Annual Survey of Hospitals.

AHA said they planned to diversify further intoambulatory care. They perceived the advantages tobe increased revenues, larger market share, greaterinpatient occupancy, and the improved ability tocompete with area providers (275).

Hospital-based ambulatory surgery facilities canbe particularly attractive in rural areas. They requirelimited capital, are convenient for physicians, and

are a major source of surgical emergency care for the

community. However, many hospitals are concernedabout their profitability because of low patientvolumes and changes in reimbursement (see ch. 5).

Another ambulatory care option for-rural hospitalsis the sponsorship of primary or urgent care clinicsand group practice centers. Physicians may some-times find these arrangements attractive becausethey ensure back-up assistance and remove many

administrative responsibilities from the physician.


For hospitals, the benefits include working moreclosely with physicians to capture and retain pa-tients, stabilizing the physician practice, and im-proving the delivery of primary care services.However, obstacles to rural hospital diversificationinto

q

q

q

q

q

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primary care may include:

difficulty recruiting and retaining physicians;hospitals’ lack of knowledge and experience inprimary care delivery;opposition by the local medical community;competition from primary care physicians andhospital emergency rooms;unstable financial condition of the hospital orprimary care practice; and

lack of patient awareness or acceptance due topoor marketing and quality assurance.

Nationwide, the number of hospital-operated free-standing centers providing primary or urgent careservices had risen to 1,003 in 1988 (362). No data

Box 6-F—Example of Hospital Diversification Into Primary Care

In the mid-1970s, Roanoke-Chowan Hospital in

Hertford County, North Carolina, opened a primarycare center in Gatesville (25 miles away in Gates

County) to make health care there more accessibleand comprehensive. (Gates County is predomi-nantly poor and has one of the highest infantmortality rates in the State.) The hospital’s outreacheffort was unusual in that it was believed to be thefirst case of a North Carolina public hospitalproviding such services beyond its county borders.Development of the satellite program involvedinitial foundation support and the cooperation andassistance of the Gates County commissioners anda nearby State-supported rural health clinic. Thecenter was to be staffed full-time by a family nursepractitioner with onsite supervision from a hospitalemergency room physician 20 hours a week Centerservices were to include a pharmacy, diagnostic

d i i f i d



( )specifically exist for rural hospitals.

Hospital-affiliated primary care in rural areastakes various forms, including:

1.

2.

3.

Hospital-based and sponsored primary care

clinics—In this model (used by many IndianHealth Service hospitals), the hospital deliversthe primary care. In one example, an 80-bedrural hospital in North Carolina provided anonsite facility and operating subsidies to at-tract a primary care group practice to thehospital campus (485).

Hospital-based certified rural health clinics

(RHCs)--Becoming a Medicare-certified RHCmay help a rural hospital’s ambulatory carediversification efforts. As noted in chapter 3,hospital-based primary care clinics under thisprogram are paid a rate covering all reasonablecosts for serving Medicare and Medicaidpatients if they offer the use of midlevelpractitioners at least 50 percent of the time.However, many rural hospitals remain una-ware of this opportunity, find midlevel practi-tioners unavailable, are in States that limitMedicaid reimbursement for their services, orface other discouraging factors (see ch. 7). Asof 1989, no more than 25 hospitals had beencertified as RHCs (see ch. 5).

Hospital-sponsored, satellite primary care cen-

ters-satellite clinics extend the hospital’sreferral base and provide primary care to ageographically broad service area. Satellite

care, and transportation services for patients to andfrom the hospital and area specialists (485).

clinics may provide community education,screening services, other primary care serv-ices, and diagnosis and treatment for essentialemergency care. They can also provide a moreaccessible and less costly source of primarycare for poor patients who previously mayhave used the hospital’s emergency room (seebox 6-F) (190).

Corporate Restructuring

Hospitals may restructure their corporate or or-ganizational identity in order to diversify. Forexample, they may transfer certain hospital assets orfunctions to a separate corporation, such as a parentholding company of which the hospital becomes asubsidiary. This arrangement may be attractive toprivate, nonprofit hospitals wishing to protect their

tax-exempt status while diversifying into unrelatedand often for-profit businesses (31).

Hospital restructuring through the formation of parent holding companies and subsidiaries has notbecome common. A 1987 national survey of hospi-tals interested in diversification found that onlyone-fourth had created a subsidiary to operatediversification activities (275). Corporate restructur-ing is particularly uncommon in rural hospitals.About 11 percent of rural community hospitals were

168q


Box 6-G—Four Examples of Rural Primary Care Networks

MarshfieldClinic, located in Marshfield, Wisconsin, is a large private, multispecialty group practice that offersa variety of outreach programs to a large rural region of the State. Created by 6 physicians in 1916, it now has over250 physicians representing some 60 medical specialties. Since 1976, Marshfield has established 17 regional clinics,most located in small towns 10 to 100 miles from the main clinic. A regional services program provides advanced

diagnostic testing and medical education and consultation services to over 370 hospitals and health care facilitiesserving a population of 3.5 million. The program provides various mobile diagnostic services (e.g., echocardiology),and a regional reference laboratory performs about 250,000 tests annually. The Clinic has also formed theMarshfield Medical Research Foundation to provide support in such areas as physician recruitment, clinicalresearch, and administration of a federally funded clinic serving low-income patients (449).

The Southern Ohio Health Services Network, a private, nonprofit system of primary care centers, was originallycreated to attract physicians to a poor and medically underserved Appalachian region. The number of primary carecenters operated by the network has grown from 1 in 1976 to 12 in 1988, covering 4 counties and serving 30,000patients. In addition, the network manages a center that provides State-supported comprehensive prenatal care andsupplemental nutrition services. Federal funds now provide 32 percent of the network’s budget, compared with 52

percent when the network began operations. The centers share the services of some specialty physicians. They alsoshare central office financial and personnel management and centrally organized staff education (724).

West Alabama Health Services (WAHS), opened in 1973, operates 5 primary care clinics, a 20-bed hospital,and a 52-bed nursing home and serves 8 counties in rural Alabama. Greene County, site of the central office andmain medical center, is one of the five poorest counties in the Nation. In response to a high incidence of infantmortality and teen pregnancy in the area WAHS began the Rural Alabama Pregnancy and Infant Health Project



mortality and teen pregnancy in the area, WAHS began the Rural Alabama Pregnancy and Infant Health Project,providing preventive care with the support of a private foundation and participation by the district healthdepartment, an urban community health center, and university medical center. WAHS also employs dentists andspecialists in mental health, nutrition, hypertension, and preventive health, and it has linkages with area Head Startand elderly meal programs. WAHS now provides more than 100,000 patient visits a year; nearly one-fifth of itspatients rely on transportation services provided by WAHS. The central office handles all purchasing, billing andother administrative support requirements for the centers (135).

United Clinics--some rural private practices have also used satellite clinics to expand services. In 1965, twoprivate physicians (a family practice physician and a radiologist) formed United Clinics, a private multispecialtygroup practice in rural North Dakota. The group expanded into internal medicine, obstetrics, pediatrics, and generalsurgery, and now has 17 physicians. Over a period of 20 years, United Clinics established six satellite clinics servingnine counties in North and South Dakota. Each clinic maintains x-ray, laboratory, and minor surgery capability tosupport the delivery of basic primary care and some specialty services (536).

part of a holding company in 1987, and just 6 percent networks that permit both operational efficienciesoperated a subsidiary (625).

8For publicly owned

hospitals, there are several legal restraints to corpo-rate restructuring (see ch. 7).

Primary Care Facility Diversification

Like hospitals, some primary care centers havesought to diversify their services in order to providea fuller array of health care while maintaining orimproving their financial standing. These centersmay depend on government funding (e.g., as com-munity health centers (CHCs)) or operate as privatepractices. One emerging “diversification” strategyis the development of satellite clinics or multicenter

and service expansion (see box 6-G).

Satellite clinics staffed by midlevel practitionerscan be used to expand primary care services,particularly in sparsely populated areas where theremay be no local physician. Such midlevel practition-ers can operate with considerable autonomy, re-

ceiving routine clinical supervision and supportfrom physicians in other communities. In one clinicin a small isolated South Dakota community, forexample, a physician assistant (PA) is the soleprovider of care. The clinic is located between twoIndian reservations and serves three of the area’spoorest counties. The PA can call in prescriptions tothe nearest pharmacy 55 miles away, and orders

s~cludes only rural hospitals with fewer ha n 300 Ms.

Chapter 6--Short- and Long-Term Strategies for Effective Change by Rural Providers . 169

usually arrive in the community within a day. ThePA is also allowed to have predispensed starterdoses of drugs on site for common needs (354).

Some communities have resorted to unusualarrangements to obtain urgent primary care. A small

rural community near the Colorado/Kansas borderlost all essential primary care services in late 1985when its small hospital closed and was converted toa nursing home, and the local physicians closed theirpractices and moved away. In 1986, investors fromthe community agreed to become partners with aprivate urgent care medical group in Denver, in orderfor the group to reopen the community clinic next tothe nursing home as an urgent care center. Three

physicians from the medical group were flown intostaff the clinic. None of the physicians lived in thecommunity on a regular basis and none offeredextended hours, but they were on call for emergen-cies around the clock. To ensure some continuity of care, the group also planned to negotiate contracts

to eligibility for the free school lunch program.About half of the children examined in the first yearof the project were found to need immediate dentaltreatment (485).

Hospital CooperativesFinancial problems and increased competition for

Shrinking resources (e.g., capital financing) havecompelled many rural hospitals to seek assistancefrom or cooperation with other providers. Suchalliances may be sought in order to increase opera-tional efficiencies, obtain management expertise,and enhance access to other resources.

Cooperative efforts have a solid history in thedelivery of essential rural services (e.g., electricity,credit unions). Cooperative ventures to attract andprovide health services bloomed in the 1940s, onlyto fade within a decade as community and govern-ment support declined (306). The cooperative con-



, g p p gwith regional hospitals to arrange secondary andtertiary care for patients seen at the clinic. Commu-nity support in the early stages of the venture was

reported to be excellent (723).Where no traditional primary care providers are

available, some local health departments have begunproviding primary care, often to poor patients orresidents of sparsely populated areas. For example,the health department in Price, Utah contracts witha physician to deliver primary care and case manage-ment services to Medicaid recipients and thosewithout insurance in a four-county frontier area. The

health department also has become a Medicare-certified home health agency (622).

In 1986, rural Marion County, Florida opened aprimary care center, funded through the countyhealth department, in order to reduce inappropriateuse of the county hospital’s emergency room facili-ties by indigent patients. The primary care clinicfurnished nearly 3,700 patient visits in its first 5

months of operation (222).Local health departments sometimes target a very

specific service and population. With private foun-dation and State support, the district health depart-ment in Elizabeth City, North Carolina began in themid-1970s providing mobile dental clinic services toneedy children living in a four-county region.Services include screening, education, treatment,and referral. The mobile unit serves children onsite

at area public schools; eligibility for services is tied

e t suppo t dec ed (306). e coope at ve cocept appears to have experienced a resurgence inrecent years, due to its promise of enhancingresources while preserving the independence of

individual providers. The nature of the relationshipamong cooperating facilities may vary considerably(see box 6-H for examples).

Some of the potential benefits of cooperativerelationships are:

q

q

q

q

more efficient operations from reducing dupli-cation and sharing equipment, facilities, staff and benefit plans, administrative services, mar-

keting and management talent, and other re-sources;improvement of market strength through costsavings (e.g., from volume purchase discounts),increased productivity, and improved access tocapital financing; establishment of beneficialpatient referral arrangements; and participationin ventures such as preferred provider organiza-tions and regional reference laboratories;

providing a forum for information sharing andpolitical advocacy of common causes; andstrengthening quality of care measures.

There are obstacles to these potentially advanta-geous relationships. First, a lack of trust amongcompetitors may be hard to overcome. Second, therigidity of some alliances may not suit somemembers’ needs. The alliances may limit the choiceof shared services, or they may not be flexible

enough to adapt to changes in the market for


Box 6-H—Three Examples of Hospital Cooperatives

The Rural Wisconsin Hospital Cooperative (RWHC) is a network incorporated in 1979 that now includes 18small hospitals (average 50 beds) located in southern Wisconsin, and an urban university hospital. The purpose of RWHC is to provide a base of support and a catalyst for the development of joint ventures. Modeled after thetraditional (and familiar) dairy cooperative, member participation in particular shared services is voluntary and is

contracted on a fee-for-service basis. RWHC’s projects include:q

q

q

q

sharing such diverse services as rehabilitation therapy and physician coverage of emergency rooms;development and early administration of the Health Maintenance Organization (HMO) of Wisconsin, oneof the first rural-based HMOs in the country;development and administration of the RWHC Trust, providing health and dental insurance for staff of member hospitals; anda mobile computed tomography scanner and nuclear medicine services program for RWHC members andother area hospitals.

In 1988, with support from the Robert Wood Johnson Foundation, RWHC implemented a regional approach

to improve hospital quality assurance programs and physician credentialing, enhance hospital financialmanagement capabilities, and improve hospital trustee governance (621).

Northern Lakes Health Care Consortium (NLHCC), founded in 1985, is a nonprofit cooperative network of 21 hospitals, 50 medical clinics, and 2 medical schools located in northern Minnesota. The consortium, which grewout of a series of workshops and studies in 1984, quickly became an arena for area rural hospitals and physiciansto explore solutions to common problems. NLHCC roles include legislative advocacy, technical assistance, shared

i ( di t d j i t h i ) i d ti l i t th it d ti d



services (e.g., discounted joint purchasing), ongoing educational sessions to the community and consortium, andmultifaceted research on issues such as health promotion and disease prevention.

With private foundation supportl, NLHCC has also instituted several demonstration projects aimed at assisting

member hospitals adapt to change:q

q

q

q

The Rural Health Transition Project, under which NLHCC provides matching grants and technicalassistance to consortium hospitals to assess their internal operation and service area needs, and to plan anynecessary restructuring.

A quality assurance network, to develop comprehensive quality standards and help hospitals implementquality assurance programs.

A physician recruitment program, to match medical students graduating from the University of Minnesotawith NLHCC’s member hospitals.

A regional long-term care network, which helps long-term care providers integrate existing services, assesslocal long-term care needs, and establish new services. The network provides shared technical services such

as physical therapy; inservice education; community-based outreach services for the elderly (e.g., homehealth care, case management, transportation services); marketing support; personnel recruitment; andquality assurance (261,.391).

The CARES Project (Coordinated Ambulatory Rehabilitation Evaluation Services) was created in 1979 by theMedical Center Rehabilitation Hospital at the University of North Dakota in cooperation with two rural communityhospitals. The U.S. Public Health Service provided initial funding. The goal was to provide coordinated,multidisciplinary services for rural children with multiple disabilities. CARES serves children in 10 sparselypopulated counties covering nearly one-fifth of the State.

In the first phase of the project, a core team of visiting specialists from the rehabilitation hospital traveled

bimonthly over 300 miles to each rural hospital to provide treatment and consultation to patients referred by areaphysicians. These physicians received written reports and continued to be responsible for overall patient caremanagement. In the second phase, local providers (e.g., physical therapists) were trained by rehabilitation hospitalstaff to act as part of the core staff at the clinics. Specialty rehabilitation teams now are comprised primarily of localhospital personnel, with ownership and program responsibility shifting to the rural hospital and a few localphysicians that have received special training. Because of the project, disabled children are now more likely toreceive rapid evaluation and comprehensive care (459).

lso~ces of supp@ include the Blandin Foundation and the Retirement Research Foundation (in association with the Ufivemity of NofiDakota).

Chapter 6--Short- and Long-Term Strategies for Effective Change by Rural Providersq

171

services. Third, alliances can be time-consuming todevelop and maintain because of the loosely couplednature of the cooperative relationship and thedistances between participating institutions. Otherobstacles may be legal or regulatory in nature (seech. 7).

Table 6-2 describes characteristics of 120 ruralhospital consortia or alliances existing in 1989.

9The

average rural consortium had about 15 members.One-half of the alliances included at least 1 ruralhospital with 100 or more beds, and over one-half had at least 1 urban hospital. The most commonconsortia activities were physician or staff educationprograms and shared services (403).

Rural hospitals are less likely than urban ones tobelong to an alliance. In 1987, of communityhospitals with fewer than 300 beds, 19 percent of urban and 12 percent of rural hospitals belonged toalliances (625). One-half of the rural members hadfewer than 100 beds, and nearly two-thirds had

Table 6-2—Descriptive Characteristics ofRural Hospital Consortia

a

Characteristics Mean

Age (years ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Total number of members. . . . . . . . . . . . . . . . . . . . . . . 15

Percentage with rural hospital

having 100 or more beds. . . . . . . . . . . . . . . . . . . . . . 51

Percentage with urban hospital. . . . . . . . . . . . . . . . 55

Percentage with nonhospital member. . . . . . . . . . . . 30

Number of meetings past year. . . . . . . . . . . . . . . . . . 9

Percentage with board of directors. . . . . . . . . . . . 60

Size of board of directors. . . . . . . . . . . . . . . . . . . . 10

Percentage with paid director . . . . . . . . . . . . . . . . . 44

Percentage with budget . . . . . . . . . . . . . . . . . . . . . . . . 63

Size of budget . . . . . . . . . . . . . . . . . . . . . . . . . . . $231,693

Sources of funding:

Percentage with member dues. . . . . . . . . . . . . . . . 33

Percentage with grants . . . . . . . . . . . . . . . . . . . . . 26Percentage with revenues from activities . . . 26

Percentage with other sources of revenues. . 23

Number of activities/programs offered

by consortia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Types of activities (% consortia offering

activity)



nonprofit owners (table 6-3). Rural hospitals inalliances had slightly higher expenses than did allrural hospitals (table 6-4).

Cooperative opportunities WithUrban Referral Centers

Some rural hospitals formalize their patient refer-ral relationships with urban tertiary centers andspecialists (see box 6-I). Cooperative referral net-works with urban providers may help rural hospitalsand physicians stem the outward flow of patients andrevenues to urban facilities. Conversely, referrals of complex cases from rural providers can bringsubstantial revenue to urban tertiary hospitals andspecialists.

One report found that referrals from rural areas inUtah account for 5 percent of an urban tertiarycenter’s patient days but up to 20 percent of itsrevenues (76). A study of referrals from rural familypractice physicians to university-based physicians in

mid-Missouri from 1982-85 found that the averagereferral generated nearly $3,000 in hospital andprofessional revenues within 6 months. Nearlyone-half of the referrals (110 of 225) resulted inadmissions to the university teaching hospital,representing 72 percent of all referral revenue for thehospital (213).

y)

Physician or staff education programs . . . . . . 81

Shared services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Legislative liaison . . . . . . . . . . . . . . . . . . . . . . . . 70

Marketing or community relations . . . . . . . . . . . 62

Regional planning . . . . . . . . . . . . . . . . . . . . . . . . . . 58Physician or staff recruitment . . . . . . . . . . . . . 55

Shared staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Management or financial services . . . . . . . . . . . 47

Primary or specialty clinics . . . . . . . . . . . . . . . 43

Quality assurance . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Acute-care bed conversions . . . . . . . . . . . . . . . . . 22

aBased on theAmerican Hospital Association def

-

inition, 120 rural hospital consortia were ident-

ified (see text). Not included are rural hospitals

working only with nonhospital organizations, meet-

ing only for discussion purposes or to pursue asingle activity pertaining to policy or planning

issues, and those working together mainly because

of multihospital system ownership or management

arrangements (~).

SOURCE: I. Moscovice et al., “The Development and

Characteristics of Rural Hospital Consor-

tia,” contract paper prepared for the Rob-

ert Wood Johnson Foundation Hospital-based

Rural Health Care Program, New York, NY,

1989.

Rural hospitals and physicians benefit from suchreferral arrangements by:

. developing close relationships between refer-ring and referral center physicians that lead toside benefits (e.g., occasional practice coveragefor referring physicians);

gAhospi~~i~ce~this~bleis de f i n edbyAHAas aformal lyorganizedgroupofhospi ta l s orhospitalsystems thathave COrnetOget.herfOrSpeC~lC

p~ses~dbvespatiicmabastiptiteti.


Table 6-3—Nonmetropolitan Hospitalsa Under 300Beds in Alliancesa by Bed Size and Ownership, 1987

Ownership

Bed size Government Nonprofit Total

6-24 . . . . . . . . . 5 7 12

25-49 . . . . . . . . 27 28 55

50-99 . . . . . . . . 29 50 79100-199 . . . . . . 27 66 93200-299. . . . . . 10 39 49

Total . . . . . . 98 190 288C

aComnunity hospitals defined here as all non-Federal,

short-stay, nonspecialty hospitals (see app. C).bAlliance~ are defined by the American Hospital

Association as a formally organized group of

hospitals or hospital systems that come together

for specific purposes and have specific membership

criteria.c

For-profit hospitals in alliances numbered 3 (1

percent of total).

SOURCE: Office of Technology Assessment, 1990. Data

q

from American Hospital Association’s 1987

Annual Survey of Hospitals.

providing local followup care for patients

Table 6-4-Total Expenses per Hospital forNonmetropolitan Hospitalsa in Multihospital

Systems and Alliances, 1987

In

Total multihospital In

Bed size rural systems alliances

6-24. . . . . . . . . . . $1,357

25-49. . . . . . . . . . 2,747

50-99. . . . . . . . . . 5,907

100-199. . . . . . . . 12,820

200-299. . . . . . . . 25,526

300-399. . . . . . . . 44,681400-499. . . . . . . . 48,264

500 or more. . . . 85,712

$1,6612,9876,35213,71024,39549,68327,05996,129

$1,4543,0397,62815,38627,93445,00042,62577,908

Total. . . . . . . . $7,639 $7,830 $7,842

a c o m u n i t y hospitals defined here as all non-Federal,short-stay, nonspecialty hospitals (see app. C).

SOURCE: Office of Technology Assessment, 1990. Data

from American Hospital Association’s 1987

Annual Survey of Hospitals.

training and development, and provider recruitment.



q

q

p g p p

treated at urban facilities;

receiving periodic support of urban specialists

to perform certain procedures (e.g., uncompli-

cated surgeries), to gain access to sophisticated

technologies, and to offer clinical training and

expertise; and

enhancing the overall image of the local hospi-

tal.

However, efforts to formalize referral relationships(e.g., via contracts) may encounter drawbacks.These may include legal problems associated with

self-interest in making referrals (see ch. 7) and limitson the use of alternative referral options.

Alliances Between Primary Care Providers

Some rural primary care providers have alsodeveloped cooperative arrangements. The FederalGovernment has recently encouraged CHCs toestablish cooperative relationships with each otherand with other health and social agencies.

10Cooper-

ative activities have included recruiting physicians,establishing computerized information networks,channeling low income patients to prepaid services,providing sources for continuing education, andsharing staff, equipment, and other resources (585).Some CHCs have linked management services toimprove activities such as grantsmanship, board

g p , p

Box 6-J gives some examples of primary care

alliances that have apparently been successful.

CHC alliances with area agencies on aging

(AAAs) are a specific response to a need for greater

linkage between health care and other services for

the elderly. AAAs were created to provide acomprehensive and coordinated set of services forthe elderly (e.g. home-delivered meals, informationand referral, transportation) (Public Law 93-29).Rural AAAs appear to have smaller budgets andmore limited ranges of services than do their urban

counterparts (287).

In 1987, the U.S. Public Health Service andAdministration on Aging undertook a joint initiativeto increase cooperation between CHCs and AAAs.Cooperation may, for example, involve the use of AAA senior centers as satellite clinics for CHCs,andthe provision of dental services to the elderly byCHCs. CHCs can provide many of the basic health,

nutrition, and preventive care services that AAAsmay be unable to offer (box 6-J) (460).

The mandates of both CHCs and local healthdepartments (LHDs) to provide basic health servicesto the poor and disadvantaged may lead to duplica-tion of services. With the recent involvement of many LHDs in primary care, CHCs and LHDs in

l~e~b~cH~~semiceprovid~ sF1~~&toa~ut120cHcsbe~een 1984afid l986tosuppoficomofi~activities,hop@todemom&ate

their effectiveness and encourage their development elsewhere without further funds. A formal evaluation of these efforts is planned for 1990 (585).


Box 6-I—An Example of a Rural-Urban Hospital Alliance

Mercy Hospital Medical Center, a nonprofit535-bed tertiary care facility in Des Moines, Iowa,has established a cooperative network linking

Mercy and 38 rural hospitals within a 100-mileradius. The network attempts to improve andexpand services of participating rural hospitals andincrease patient referrals to Mercy from ruralphysicians. Witnessing greater competition amongDes Moines hospitals, Mercy in 1985 surveyed arearural hospital needs and subsequently organized anetwork of outpatient specialty clinics. By 1989,physicians from 20 specialties were providing over80 clinics in 28 rural hospitals. Urban consulting

specialists are now encouraged to use local hospitalresources (e.g., laboratory and x-ray facilities) thatgenerate added revenue for the rural hospital. Toassist the specialists and keep local physiciansfamiliar with new medical technology, Mercy alsoprovides certain clinical technology services and

i t ( t i d EKG hi ) t

probably be unable to reverse its lease or sale to theMHS. Contract management by an MHS is alsorelatively irreversible. It appears to have improvedthe management of many hospitals (315), but it maybe perceived by some hospitals as a means by anMHS to eventually gain more control.

Many of the conditions that lead hospitals todiversify or participate in cooperatives also apply to

joining MHSs. In addition, hospitals may turn toMHSs because of immediate financial crises. Spe-cific factors might include:

q

q

q

physical plant deficiencies that the hospitaldoes not have the capital to remedy;

the perceived opportunity for the hospital toimprove access to capital and specializedmanagement expertise through an MHS; and

pressure from local community leaders who areanxious to stabilize the hospital’s operatingenvironment (282).



equipment (e.g., computerized EKG machine) atminimal cost to the local facility.

The Mercy Hospital Network has formal affilia-

tion agreements with 11 rural hospitals, 7 of whichhave requested Mercy for an administrator. Tomaintain the local hospital’s autonomy, the admin-istrator is accountable to that hospital’s board of directors. All rural hospital affiliates may obtainlow-cost management and clinical consultationservices, staff education programs, and assistancein recruiting physicians and allied health profes-sionals. Network hospitals without formal affilia-tions may purchase similar services at somewhat

higher prices (81).

rural areas may find it advantageous to shareservices and resources (box 6-J).

Multihospital Systems

A multihospital system (MHS) is broadly defined

by the American Hospital Association as two ormore hospitals that are owned, leased, sponsored, orcontract-managed by a central organization (107).MHSs may be either nonprofit or investor-owned.Nonprofit systems are tax-exempt organizations,usually regional in scope. Investor-owned systemsare for-profit, shareholder-based institutions usuallycontrolled by a central management.

Affiliation with an MHS requires yielding some

or all of a hospital’s autonomy. A hospital will

For the MHS, advantages of recruiting rural hospi-tals may include eliminating competition, enablingmore control over regional markets to gain patient

share and profits, and improving the delivery andaccess of certain health services. Box 6-K providestwo examples of MHSs.

Rural participation in MHSs has waxed andwaned. From 1950 to 1983, the number of smallrural hospitals (with fewer than 100 beds) that joinedsystems increased from 32 to 490 facilities. Mosthospitals in MHSs (46 percent) were under contract

management (345). By 1985, more than one-third of rural community hospitals were in MHSs (31). By1987, however, the number of rural communityhospitals in multihospital systems appears to havedeclined to about 25 percent of rural communityhospitals with fewer than 300 beds (table 6-5).

The recent decline in MHS participation by ruralhospitals is probably indicative of their fears that:

. their autonomy and flexibility will be dimin-shed;

. MHS management will neglect local interestsand needs (e.g., staff will be replaced withcorporate-designated personnel); and

. local revenue may be lost from the community(345).

On their part, many MHSs are reportedly finding

rural hospitals to be less attractive as investments.




Box 6-K—Two Examples of Multihospital Systems

Memorial Hospital and Home, a 29-bed hospital and 102-bed nursing home in rural Minnesota, in 1984 wassuffering from declining utilization, staff turmoil, a negative community image, and a $250,000 operating deficit.In 1985, Memorial’s board of directors signed a 2-year agreement with Saint Luke’s Hospitals-MeritCare, a largetertiary hospital located 70 miles west in Fargo, North Dakota, to contract-manage Memorial.

Neither hospital had previous experience with such an arrangement. The contract required Saint Luke’s to hirean administrator and in the first year develop new operating procedures, strategic plans, and marketing programs;conduct board training; evaluate and revise administrative and nursing policies (e.g., a new wage system); andreview quality assurance activities. By the second year, new purchasing and computer services contracts wereestablished, and outside specialists from Saint Luke’s were brought in as needed to run clinics and provide staff education.

By 1986, the hospital showed a profit of $97,000. In 1987, remaining problems included a lingering low patientcensus, some negative community feelings, and the return of unexpected operational losses; however, most boardmembers agreed to a new contract for an additional 19 months, allowing Memorial to participate in a jointpurchasing agreement with Saint Luke’s and Voluntary Hospitals of America (246).

Intermountain Health Care, Inc. , a nonprofit MHS, was founded in 1975 in Salt Lake City, Utah to assumeownership of 15 hospitals in the region divested by the Mormon church. IHC now manages, leases, or owns 23community hospitals (14 of which are rural) in 3 States. It also operates 4 freestanding ambulatory surgical centersand 25 rural primary care clinics that serve as outreach facilities to the rural hospitals. Services provided to itsmember facilities include:

. a cardiac emergency care network linking rural hospitals and physicians with area tertiary care centers;access to high risk perinatal care lithotripsy and central lab services;



. access to high-risk perinatal care, lithotripsy, and central lab services;

. crosstraining and continuing education to retain nurses;q sharing of medical directors between some hospitals, helping smaller facilities with credentialing and quality

assurance activities; andqgroup purchasing for supplies, data processing services, insurance, and employee health benefits.Intermountain has recently faced excess capacity and increasing losses in its rural hospitals, forcing it to

consider liquidating hospitals or converting them to other use (115).

Overall, the effectiveness of MHSs in helping Commission on Accreditation of Healthcare Organi-rura1 hospitals to survive is uncertain. A national zations, and they had a higher average expense perstudy of MHSs from 1984 to 1987 found littledifference in the profitability and scope of servicesbetween autonomous rural hospitals and those inMHSs. However, rural hospitals in MHSs had lowercosts per admission, were twice as likely to enter intoeconomic joint ventures with physicians, and pro-vided less uncompensated care than did independentrural hospitals. Among rural hospitals in MHSs,nonprofit systems offered a greater number of out-of-hospital services, engaged in more economic

joint venture and managed care activity, and had lessuncompensated care and lower costs per admissionthan investor-owned systems, but they were lessprofitable and had higher room charges (418). Anearlier study found similar results; there were fewdifferences in performance between hospitals ownedby or leased to MHSs and MHS-managed orindependent hospitals. Owned or leased hospitalswere more likely to be accredited by the Joint

patient day, but they did not provide more services(88). Neither study examined whether rural hospitalsin MHSs had improved access to capital-the mostcommonly perceived advantage of MHS participa-tion.

Local Hospital Mergers and Agreements

Where a community has two or more hospitalsproviding duplicative services and suffering excess

capacity, consolidation of these services may be asuccessful strategy (see box 6-L). If local hospitalsmerge their organizations and assets, or enter into aformal agreement regarding the division of services,they can each provide only those specialized serv-ices for which they are best suited (e.g., one hospitalprovides obstetrical services, another delivers long-term care). These arrangements may then helpsubsidize the continued provision at each hospital of



Chapter 6--Short- and Long-Term Strategies for Effective Change by Rural Providers q 177

and reduce competition from urban hospitals. Typi-cal incentives are:

q

q

q

q

q

q

office space and equipment;subsidized malpractice insurance;patient referrals from hospital satellite centersor through managed care contracts;

management services (patient billing, market-ing support, iiancial counseling);continuing education; andguaranteed income or cash incentive compen-sation.

A recent study asked physicians in nine ruralMidwestern communities which factors were impor-tant in selecting a hospital for practice. Support

services of highest interest included accreditedcontinuing education, hospital liaisons to ease com-munications with administration, medical staff of-fices with effective support and communications,and assistance in developing patient information andsatisfaction surveys. Services noted of least interestwere billing services and opportunities to participate

address changing utilization and revenue patterns,and joining alliances or multihospital systems toshare resources and lower financial risks.

Some strategies have been used widely and successfully. The number of rural hospitals, forexample, that have become swing bed providers has

grown to about half of those eligible, allowing thesefacilities to diversify away from declining acute careutilization and meet growing post-acute care de-mands.

Other strategies have been tried with morelimited success. For example, rural hospital mem-bership in multihospital systems appears to bedeclining. It is not clear whether certain types of

rural hospitals are more likely to benefit frominclusion in multihospital systems.

Little is known about the success of manyefforts, and no effective way now exists to predict

and communicate their success. Also, little oppor-tunity is available for communities to compare ande change idea E ample of apparentl cce f l



in managed care arrangements and joint ventures(534).

SUMMARY OF FINDINGS Many rural providers have found effective means

of adapting to changes in their environment. There are numerous examples of efforts by rural hospitals,CHCs, and other facilities to support effectivechange. Many have found ways to strengthen facilitysolvency and stabilize operations in the short term(e.g., renewed fundraising, tougher collection poli-

cies). Also, many rural facilities have institutedstrategies that reconfigure their organizational andservice structure for the longer term. These effortsinclude converting or diversifying service bases to

exchange ideas. Examples of apparently successfulstrategies include improvements in leadership andmanagement, hospital conversions to alternative

health facilities, local hospital mergers, hospital-physician arrangements, and CHC consortia andcategorical care initiatives.

Other rural providers have not availed themselves of helpful methods and strategies, in part

because it appears they have been slow to acceptnecessary change. For example, despite significantdeclines in inpatient utilization (see ch. 5), many

rural hospitals remain full-service acute-care facili-ties, apparently without the will or resources tothoroughly examine their roles and capabilities andmake significant structural changes.



CONTENTSPage

INTRODUCTION181

... ... ... ... ... ... ... ... ... ... ... ..*. . """"""""""""""""""""`"""""""9""FEDERAL ISSUES... . . . . . . . . . ... ... +...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Medicare Conditions of Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Rural Health Clinic Certification ..........+.. ...........”...O’.O.S~+. +“.”-.~.-+..+.’~. 182Performance Standards for Community Health Centers . . . . . . . . . . . . . . . . . . . . . . . . . . .....Tax Laws Affecting Health Facilities . . . . .. ., .. ... ... ... +..~” .+..~..”+++..”+++.” .~~”+~+ 183Fraud and Abuse Regulations . . . . . . . . . . . . . . . . . . . .......~........++..9..00 •+++~0....+.. 184Antitrust Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

STATE ISSUES 188. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....*.* ....... ...**.. •,*~.*. q*.””.+ “.

Facility Licensure . . . . . . . . ,,.....+. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

Certificate-of-Need Requirements . . . . . . . . . . . . . . . . . . . . . . . . . ...+......+..~’+=”~.c’=”~ .“+ 188Property Tax Laws .. .. +. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q . . . . . . . . . . . . 189

Public Hospital Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190

SUMMARY OF FINDINGS . . . . .. .. .. .. +. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192






Home Health Services—Hospital-based homehealth programs in some rural areas have difficultycomplying with Medicare regulations because theylack a full-time RN director (219). Some rural localhealth departments with home health agencies havealso had difficulty justifying and affording a full-time RN who is responsible solely for the home

health service (519). Other rural home health agen-cies have expressed concern about their ability toobtain the required qualified instructors to conductclassroom teaching for home health aides (279).

Swing Beds--Some rural hospitals believe thatFederal regulations on swing beds are too stringentor unclear. To qualify for swing-bed reimbursement,patients must meet the same standards of medical

need as patients who qualify for reimbursement inskilled nursing facilities. Hospital patients dis-charged from acute care who need transitional careless intense than skilled nursing care are thusineligible for Medicare swing-bed reimbursement(194). This creates a gap in health care coverage,particularly in areas with no easily available homeh lth i H it l l l i th t M di

q

q

cash flow problems for smaller providers heav-ily dependent on such sources of payment.(Once certification is received, RHCs are enti-tled to retroactive reimbursement under thenew form of payment.)

Administrative requirements—The paperwork

burden necessary to complete extensive costreports and other requirements may be over-whelmingly complex for small unsophisticatedRHCs with few administrative staff. Suchcenters may have to obtain costly outsideaccounting and financial assistance. RHCs canalso encounter operational difficulties whenStates conduct annual recertification surveyswithout prior notice. Small centers where staff

handle both administrative and clinical dutiesmay be unable to fulfill all of their clinicalobligations during unannounced recertificationvisits (713).

Requirements for midlevel practitioners—A

midlevel practitioner must be on site at an RHCat least 50 percent of the time the facility is



health services. Hospitals also complain that Medi-care intermediaries

4inconsistently interpret billing

instruction manuals when classifying swing-bedpatients as receiving skilled or intermediate care,creating confusion and limiting swing-bed use(732).

Rural Health Clinic Certification

Faced by increased financial pressures, ruralhealth facilities are seeking ways to enhance reim-bursement under Medicare and Medicaid. Recentcongressional actions to improve reimbursement forcertified rural health clinics (RHCs) (see ch. 3) haverenewed provider interest in becoming or remainingcertified as RHCs. However, providers often lack knowledge about the program or are concernedabout RHC regulations. Major concerns include:

. Delays in certification—Many providers seek-

ing RHC certification report that the applica-tion process is burdensome and lengthy, oftenlasting 6 or more months (87,713).

qDiscontinuance of billings—Providers must

stop billing Medicare and Medicaid whileawaiting RHC certification, creating possible

q

at least 50 percent of the time the facility isopen. (Congress reduced this requirement from

60 percent in 1989 (Public Law 101-239).)Thisrequirement may be difficult for some clinics tomeet. First, some RHCs have problems recruit-ing and retaining midlevel practitioners due tosupply shortages, or due to restrictions in someStates that affect the ability of midlevel provid-ers to practice medicine (see ch. 12). Second,rural providers with several clinic sites thatshare midlevel practitioners on a part-time

basis may be unable to qualify each site as anRHC, because the midlevel practitioners maynot always be available at each site at least 50percent of the time the center operates.

Limited guidance for provider-based clinics—

Health Care Financing Administration (HCFA)regulations for RHCs have focused on free-standing clinics (the vast majority of RHCs).Some observers report that the regulations lack sufficient guidance for provider-based sites(e.g., in hospitals or skilled nursing facilities)on acceptable methods of determining reasona-ble costs for reimbursement (523). Provider-based clinics are supposed to receive fullcost-based reimbursement (see ch. 3).

4 M~ & - a e ~teme~~e~ m e fi~c~ ~gent~ (~ic~y Bllle cross p l ~ or co~erci~ ins~~ce ~) ~der contract to th e Health CaIe Ftic@

Administration for administration of peci i lc Medicare tasks (e.g., deter r n i n i ng reasonable costs for iterns, making payments).




tions do not benefit private interests more thanincidentally. In theory, this standard may not bedifficult to meet. For example, the IRS has ruled thata rural area with a significant need to attractphysicians could use community funds to constructa medical office complex, because any personalbenefits physicians might derive would be incidentalto the community benefit (298). However, theanalysis that must be done to demonstrate thiscondition can be difficult. It requires that benefitsprovided by the physician to the hospital and thecommunity be quantified and compared to therecruitment or retention benefits provided to thephysician. This is not an easy task, since communitybenefits are often subjective and not easily quantifia-ble. Uncertainty about what hospitals may offer toattract and retain physicians is exacerbated by therecent IRS announcement that exempt hospital-physician relationships will be subject to heightenedscrutiny.

Unrelated Business Income

Although in considering these issues the IRS hasindicated no “across-the-board” recognition of arural hospital’s role, courts have been sympathetic torural hospitals. For example, in Hi-Plains Hospitalv. United States, the court held that a rural hospital’spharmacy sales to private physicians’ patients werenot taxable income because the pharmacy’s avail-

ability was an inducement to practice medicine inthe hospital, and thus it contributed to the goal of making medical services available (257). Incomefrom rent of office space to physicians has not beenconsidered taxable because locating physicians onthe hospital campus is, in the IRS’s view, substan-tially related to the hospital’s provision of medicalcare, whether the hospital is urban or rural (297).

Tax-Exempt FinancingAs noted in chapter 5, access to tax-exempt

financing is crucial for many nonprofit rural hospi-tals. Under the IRS Code, interest income from newbonds issued after August 1986 to finance tax-exempt health facilities is exempt from Federal taxif:



Tax-exempt organizations are subject to Federal

tax on income from any regular business that is notsubstantially related to the organization’s charitablepurpose (IRS Code Sections 511(a), 512(a)(l),513(a)). These activities may be restricted not onlyby imposing tax, but also by concerns that status of the facility (or of bonds financing it) may beendangered. Recent proposals by Congress broadenthe types of income classified as unrelated and limitthe deductions permitted in computing taxable

income (e.g., from hospital gift shops, royalties, andrent from organizations hospitals control).

In general, services provided by hospitals tophysicians in private practice or to their patientsgenerate taxable income. Such services includereference laboratory, administrative, and pharmacyservices (294,295,296,299). However, the IRS hasrecognized to a limited extent that rural hospitalsmeet unique community needs that justify taxexemption of such activities. For example, a hospi-tal’s reference laboratory service may be exempt if the hospital is geographically isolated and theservices are not reasonably available from commer-cial sources (299). This test is fact-specific, how-ever, and does not provide general guidance for ruralhospitals.

q

q

The

all of the property obtained with the proceeds of

the bonds is owned by the tax-exempt provider,andno more than 5 percent of the facilities financedby bond proceeds are used by a nonexemptperson or in an unrelated trade or business (IRSCode Sections 103, 141, 145).

6

Fraud and Abuse Regulations

Antikickback Provisions

The Medicare and Medicaid antikickback provi-sions (42 U.S.C. § 1320a-7b) were first adopted byCongress in 1972. The provisions were intended toprovide penalties for certain practices that have beenlong considered unethical by professional groupsand that contribute significantly to the cost of theMedicare and Medicaid programs. The regulationsprohibit offering, soliciting, paying, or receiving

“any remuneration (including any kickback, bribe,or rebate) directly or indirectly, overtly or covertly,in cash or in kind” in exchange for or to induce anyof the following actions:

q referring an individual to a provider for thereceipt of an item or service that is covered byMedicare or Medicaid; or

Chapter 7--Regulatory and Legal Concerns for Rural Health Facilities . 185

q purchasing, leasing, or ordering any item orservice that is covered by Medicare or Medi-caid.

If read literally, these regulations can be viewed

as prohibiting a number of relatively commonactivities. The provision of free coffee by a hospital

to members of its medical staff could be interpretedas an inducement to the physicians to admit theirpatients to the hospital. Although this particularcommon practice is unlikely to warrant prosecution,health care providers may find it difficult to clearlydistinguish between permitted and prohibited con-duct.

Many hospital strategies to recruit or retainphysicians (e.g., offering physicians financial assis-tance in establishing a practice) can trigger antikick-back provisions. Such arrangements might beviewed as the furnishing of compensation to aphysician by an entity to which the physician referspatients.

The ownership of hospitals by physicians mayalso be viewed as a violation of antikickback laws if

Services (DHHS) to develop regulations specifying“safe harbor” practices that would not be consid-ered violations of the statute (Public Law 100-93).The proposed regulations were issued in January1989 (54 FR 3088), but they have not resolved theuncertainty. For example, one of the proposed ‘safeharbors” would permit a physician to receivedividends from investments in large, publicly tradedcompanies that operate entities to which the physi-cian refers patients.

7The legality of this practice,

however, was never seriously (questioned. What hadbeen (and remains) uncertain was the permissibilityof physician investment in hospital-physician jointventures, or physician ownership of communityhospitals. Similarly, the proposed regulations wouldprotect the purchase by a physician of the practice of another physician who is retiring or is leaving thearea. However, the regulations say nothing aboutwhether a hospital may purchase a physician’spractice--a question that is likely to be far moreimportant for the rural hospital trying to maintain itspatient base. Final “safe harbor’ regulations areexpected to be published in 1990.



also be viewed as a violation of antikickback laws if these physicians tend to refer patients to the hospi-

tals they own. These “self-referrals" by physiciansmay be especially prevalent in rural areas where thephysician-owned hospital is the only local hospital.

In other rural communities, some for-profit multi-hospital chains (e.g., Hospital Corp. of America andAmerican Medical International) have explored thepossibility of selling unprofitable facilities to mem-bers of the hospitals’ medical staffs (584). Where arural hospital is unprofitable, the members of itsmedical staff may be the only persons with sufficientcapital to take over the facility and prevent itsclosure. Also, physician ownership may mean thereis sufficient interest by local physicians in maintain-ing a practice at a nearby hospital, and that at leastsome of the income from the hospital’s operationswill remain invested in the community.

“Safe Harbor” Regulations

In an attempt to resolve some of the confusionsurrounding the meaning and scope of the antikick-back statute, Congress recently directed the Secre-tary of the Department of Health and Human

Antitrust Issues

Mergers and Acquisitions

Some rural hospitals may find it increasinglydesirable to combine their assets and operations.However, recent increases in government oversightand enforcement of hospital consolidation activityby the U.S. Justice Department and by the FederalTrade Commission (FTC) raise important antitrustissues for these rural hospitals. Section 7 of theClayton Act (15 U.S.C. 12-27) prohibits mergers oracquisitions that may substantially lessen competi-tion or tend to create a monopoly. The Clayton Act’sapplication requires a prediction of the likely effectof the merger or acquisition on consumer welfare.Guidelines for evaluating this effect were issued in1984 by the Antitrust Division of the Department of Justice.

The principles and standards contained in thesemerger guidelines have recently been applied in twocases involving mergers of nonprofit hospitals--onein Roanoke, Virginia, the other in Rockford, Illi-nois.

8In each case, the Federal Government sought

k r a l facilities are exempted from legislation passed by Congress in 1989 that denies Medicare payment for clinical laboratory servims if th e

referring physician has a fmcial interest h or receives compensation from, the entity that provides the service Pnbl i c Law 101-239).

gfior @ 1988, the Federal agencies responsible for enforcing the antitrust laws had challenged only three mergers or W@ t i o n s i nvo lv ing g ~ e ~

medical and surgical hospitals.






The argument that a competing physician wasexcluded based on review of that physician’s recordby the hospital medical staff is not always asuccessful defense, even in a State with a statuteencouraging such peer review. In an Oregon caseinvolving this issue (see Patrick v. Burget, 108 S. Ct.1658 (1988)), the Supreme Court held that the State

of Oregon did not actively supervise peer reviewactivities, nor did it have a mechanism for overturn-ing inappropriate peer review decisions. Therefore,the Court concluded, such activities were notimmune from antitrust challenge.

Joint Ventures

Hospitals that have a very large market share forhospital services in a particular area maybe in jointventures (e.g., for provision of home medicalequipment) that effectively limit competition bysuppliers not included in the ventures. Likewise, agroup of rural physicians who account for a majorityof the physicians in a particular community may faceantitrust risks associated with joint ventures. Agree-ments with joint venture partners to refer all patientsfor durable medical equipment or home health to the

q

q

may require SNFs to have their own nurses’station apart from the hospital’s acute-carenurses’ station. Medicare certification alsogenerally requires hospital SNFs to remaindistinct units with separate beds and staff.Complying with such standards may result inboth SNF and acute-care nursing staff being

underused, especially in small rural hospitalswhose acute-care census is low.Personnel training requirements—SomeStates limit the use of multiskilled allied healthcare personnel. Many rural hospitals incurhigher costs because they must, according toState licensure laws (and Medicare conditionsof participation), employ several full-time indi-viduals to perform tasks that a single profes-

sional could do if appropriately trained andlicensed.

Higher license fees-Certain States reportedlyhave instituted-significant increases in fees forfacility licenses, CON applications, and otherbusiness requirements for health care facilities.These fees are proportionately more difficultfor small providers than for large providers to



for durable medical equipment or home health to theventure, for example, may have antitrust implica-tions.

STATE ISSUES

Facility Licensure

State licensure standards are intended to ensurethat patients using licensed facilities will be pro-vided care of at least a minimum level of safety and

quality. (In addition to receiving State licensure,facilities wishing to be certified by Medicare andMedicaid, as noted earlier, must meet standards setby JCAHO or State licensing agencies mandatedunder Medicare conditions of participation.) Thesestandards, however, may sometimes inhibit ruralhospitals from undertaking some activities to en-hance their survival.

q

q

Operating room requirements-States gener-ally require all licensed hospitals to have fullyequipped operating rooms. Even if a small ruralhospital no longer performs surgeries due todeclines in demand and availability of sur-geons, it must continue to maintain surgicalfacilities and staff.

Hospital-based SNF requirements-Some Statelicensure laws pertaining to hospital-basedskilled nursing facilities (’‘distinct part SNFs"

for small providers than for large providers topay.

Little is known about the costs these regulationsentail, and what impact they have on rural hospitalefforts to preserve quality of care, maintain opera-tions, and adapt to environmental changes.

Where States have made substantial changes inresponse to rural hospital concerns, hospitals maystill be faced with incompatible Federal certificationregulations. The State of Montana recently re-quested a waiver of Medicare conditions of partici-pation and certain reimbursement policies fromHCFA that would permit the State to create a newclass of rural facilities (medical assistance facilities)as an alternative to a rural hospital (see ch. 8).Changes in State licensure laws are sufficient topermit such facilities to function, but changes inMedicare certification requirements are probablynecessary to make them financially viable.

Certificate-of-Need Requirements

In 1972, the Federal Government required Statesto begin instituting CON programs to more effec-tively control health care capital expenditures andother medical costs. In general, CON was seen as away of limiting unnecessary investment by hospitalsand other health facilities in new beds, plant, and





Chapter 7-Regulatory and Legal Concerns for Rural Health Facilities q 191

hospital employees from serving on the board.17

Such restrictions may make it difficult for some ruralpublic hospitals to find trustees knowledgeableabout hospital and health care issues.

Public Disclosure Laws—Most States have pub-

lic disclosure laws that require public bodies,including government-owned hospitals, to holdopen meetings and provide the public access tonumerous records of the public body. Althoughthese laws serve this purpose well, they also mayplace public hospitals at a severe competitivedisadvantage. In a rural area with more than onehospital, a public hospital is disadvantaged byhaving sensitive business plans reported on the

evening news or heralded on the front page of thelocal newspaper. In 1986, the California Legislatureaddressed this problem by amending the State’sHospital District Law to enable a district hospitalboard to order a closed session to discuss ordeliberate on hospital ‘‘trade secrets” where neces-sary to initiate a new hospital service or program thatwould, if prematurely disclosed, create a ‘ ‘substan-ti l b bilit f d i i th h it l f

Public Bidding Laws—Almost every State has acompetitive bidding process that is applicable topublic hospitals. The considerable delay and ex-pense generated by these statutes may impede orprevent rural public hospital administrators fromreacting to changing market conditions in their

purchase of property and services.Judicial Restraints

Decisions by public hospitals concerning thecredentials of medical staff are reviewed by Statecourts, both to review the hospital’s compliance withthe bylaws procedures and to affirm the underlyingmerits of the decision. In contrast, so long as aprivate hospital follows the procedural guidelines

set forth in its medical staff bylaws, courts in mostStates will not step in to second-guess the substan-tive decision of those hospitals.

Constitutional Restraints

Almost every State constitution prohibits munici-pal corporations, including public hospitals, fromowning stock or serving as a partner with a privateentity This prohibition arises out of States’ concerns



tial probability of depriving the hospital of a

substantial economic benefit. ’’18

Certificate-of-Need Laws--Public hospitals typi-cally are not empowered by their enabling acts toengage in the corporate restructurings that might beused to circumvent CON review of a major projectin many States. The ability of private hospitalcompetitors to do so thus may give them animportant competitive advantage over public hospi-tals.

Investment Restrictions--Many State enablingacts place severe limitations on the types of invest-ments in which public hospitals may place theirfunds. For example, the Illinois Investment of PublicFunds Act prohibits public entities from owningstock for investment purposes.

19In Alabama, public

hospitals may only invest in “direct obligations of the United States.”20

Restrictions of this kindprotect the public purse but also prevent publichospitals from placing hospital funds in higherinterest-yielding investments.

entity. This prohibition arises out of States concerns

about the commingling of public with private funds,and the potential “gift” of tax dollars that wouldenrich private individuals. Such absolute prohibitionfrom equity ownership precludes almost all types of

joint ventures between public hospitals and physi-cians or private hospitals. Thus, a method usedsuccessfully by private hospitals to encourage closerrelations between hospitals and physicians and toaccess additional sources of capital is usually

unavailable to public hospitals.Possible Solutions

Amendments of State public hospital enablingacts and other statutes may aid public hospital effortsto expand their scope and array of activities toenhance their survival. Also, some public hospitalshave created “parent-subsidiary” or “brother-sister” multicorporate structures to avoid statutory

and constitutional constraints. These partial solu-tions, however, are not without their own problems.First, it may be unclear whether the newly createdaffiliate can be capitalized by the governmentalbody without violating the State constitutional

17see, ~.g., ~chigm op. Atty. G en. N o. 6067, P.~ (1982).

18see Cmorfia H~th and s~e~ Code, Section 32106.

Igsee ~inois, Rev. Stat. ch. 85 ~ 2401 et s~. (1983).

~See ~ab~ Code $ 22-21-77(15) (1989).


prohibition on “public gifts.” Second, the greaterthe control by the governmental body over theaffiliate, the greater the likelihood that (for regula-tory purposes) such transactions will be consideredimproper. The adoption of these structures is clearlynot without legal risk.

A third issue involving public hospitals has beena national movement toward allowing public hospi-tals, through State enabling act amendments, to“convert’ to private, nonprofit status by selling orleasing all of the public hospitals’ assets andoperations to newly created nonprofit corporations.Once legal authority to “convert” exists, the me-chanics of conversion must be investigated. One of the major concerns in any public hospital conversion

is the degree to which the nonprofit entity thatoperates the hospital will be accountable to thepublic after the conversion. Public concerns mayinclude potential reduction of services, reduction orelimination of uncompensated care, and unreasona-ble “inside deals’ between the public body and thenew nonprofit hospital board. These concerns mustbe addressed expressly in either the lease or sales

t b t th bli b d d th

interests; or if it receives substantial income fromany business not related in a major way to thehospital’s charitable activities (e.g., sharing man-agement services). In a time when many hospitalsare considering participating in shared service coop-eratives and diversifying into new services, the

similar limits that apply to these ventures mayinhibit hospitals from carrying out such strategies.Nearly one-half of rural hospitals are private non-profit institutions, and loss of tax exemption formany would further weaken their financial condi-tion.

Some referral practices that rural hospitals might undertake to maintain their patient base and retain physicians may be subject to Federal anti-

kickback regulations.Because many providersconsider the scope of antikickback rules to be vague,certain practices deemed to be ‘safe harbors’ underthe law have been proposed by DHHS. Uncertaintyremains, however, over the legality of many prac-tices such as physician investment in hospital-physician joint ventures, physician ownership of hospitals, and hospital purchase of physician prac-ti



agreement between the public body and the new

hospital corporation, or in the new hospital corpora-tion’s articles and bylaws.

SUMMARY OF FINDINGS

Federal and State laws and regulations governingdelivery of services have created a number of concerns for rural providers.

Some State licensure rules and Medicare partici-

pation requirements are seen as inhibiting operations and strategies for effective change. Manyrural hospitals, especially smaller ones in moreremote settings, argue that standards for minimumstaffing and service requirements are impractical tofollow, because staff are unavailable, too costly, orcannot be justified due to insufficient patient de-mand. Some recent State efforts (e.g., in Montana) toalter licensure rules for struggling hospitals inisolated rural areas may face Medicare certificationrequirements that cannot accommodate anythingless than a full-service, acute-care facility.

Eligibility requirements for Federal tax exemption are seen as endangering some survival strategies of rural hospitals. A rural nonprofit hospital’sexemption from Federal income tax is threatened if it offers incentives to attract physicians that may be

seen as unduly tiering the physician’s private

tices.

Hospital mergers and physician relations are now facing greater scrutiny under Federal antitrust laws. The legality of any merger depends on thespecific competitive environment of the merginghospitals. Legal decisions regarding Federal effortsto regulate hospital mergers, however, have broughtopposing results even in factually similar cases,perpetuating the uncertainty in many hospital mar-

kets. Federal performance and certification stan-

dards for some rural clinics are seen as inappropriate or overly burdensome. Some small federallyfunded CHCs, especially in remote areas, believeFederal performance standards governing adminis-trative and clinical operations of all CHCs areirrelevant or too inflexible for their environments.Rural centers wishing to become certified ruralhealth clinics believe the process of certification isunduly long, complex, and sometimes impractical.

State CON rules and other laws that place limits on the number of new long-term care beds are sometimes seen as preventing rural hospitals from converting away from acute care. Such restrictionsin all but a few States are believed by some ruralhospitals to restrict conversions of excess acute care

beds to nonacute or other specialty care beds. Some

Chapter 7--Regulatory and Legal Concerns for Rural Health Facilities q 193

States, however, have changed their CON laws toallow hospitals to more easily convert beds ordiversify into new services.

State and local property tax exemptions for hospitals and other providers are facing greater scrutiny. At least seven States recently have chal-

lenged property tax exemptions of hospitals andother providers. Loss of tax exemption might furtherendanger the financial viability of some small ruralfacilities.

Rural public hospitals face strict limits on their ability to diversify and compete. Strict State ena-bling acts and constitutional provisions are seen asinhibiting survival efforts of rural public hospitalswhen they:

q

q

q

q

q

prohibit a public hospital’s operation of relatedbusinesses;

limit operations to a specific service area;

limit trustees to residence in a specific area(possibly restricting the hospital’s ability tofind qualified governance);

require public disclosure of sensitive businessand marketing strategies; and

place other restrictions on investments, medicalstaff credentialing, and joint ventures.

Solutions being considered by States to theserestraints on public hospital activity are not withoutrisk. For example, States that allow public hospitalsto restructure to private, nonprofit corporation status

may lessen the hospital’s public accountability.

.





CONTENTSPage

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197DETERMINING A STANDARD OF SERVICES FOR RURAL COMMUNITIES . . . 197Washington: Five Health Service Groups ... ... .. .$..*.......*..*........***?.**. 197Utah: Basic Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

CREATION OF ALTERNATIVELY LICENSED FACILITIES INRURAL AREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .199

Montana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

Initiatives in Other States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202Comparison of State Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203Recent National Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .204

STATE-PROMOTED INTEGRATION OF SERVICES . .. .* ., .. .. .* *. .* .* ,* ,. .. *. , 204LOCAL TAX INITIATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .205SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

TablesTable Page



Table Page

8-1. Basic Health Services for Rural Areas (Washington State) . . . . . . . . . . . . . . . . . . . . . . 1988-2. Recommended Health Services by Size of Community (Utah) . . . . . . . . . . . . . . . . . . 199

Chapter 8

Collaborative Opportunities BetweenRural Health Facilities and Government

In recent years, many rural health care facilitieshave found that their prospects for survival areenhanced by working with Federal, State, and localgovernments interested in developing new ap-proaches to improve facilities and services. Thischapter will first discuss efforts by some States toconceptualize an appropriate or minimally accepta-ble array of services for rural communities. Second,the chapter examines work by some States, and morerecently the Federal Government, to develop alter-native delivery models for rural facilities. Theseefforts focus mostly on redefining what is meant bya “hospital” and rearranging the existing regulatoryframework to enable rural hospitals--especiallythose that are financially troubled or are the onlylocal facility-to have a structure more appropriateto local needs and capabilities. Next, it offers someunique examples by States to support the integration

At least two States have developed conceptual

frameworks of basic services and delivery modelsthat should exist in rural communities. Theseframeworks, described below, address such funda-mental questions as:

q

q

q

Current scope—What are the scope, volume,purpose, and effectiveness of services nowbeing delivered? Who is delivering them?

Appropriateness—Are the services appropriatefor the current and expected level of demand

and community capability to support them?Are they meeting basic health needs? Have thecommunity’s perceptions and feelings beenadequately understood and addressed?Facility/community cooperation—Are local fa-cilities doing enough to deliver appropriateservices, assure their accessibility and quality,and control costs? Would the community bewilling to accept the loss of certain services it



unique examples by States to support the integrationof health services by rural facilities. Finally, thechapter examines how some local governments inrural areas are finding ways to provide sorely neededtax support to area facilities.

DETERMINING A STANDARD

OF SERVICES FOR RURAL

COMMUNITIES

Ideally, the development of services and facilitiesthat reflect local needs and conditions begins bydetermining the essential service requirements of acommunity. This task is not an easy one. Each ruralcommunity has its unique set of service deliveryproblems, resources, and priorities. Some smallhospitals, struggling with declining utilization andpoor operating margins, have considered severelylimiting their scope of services. But for sole commu-nity providers serving wide and sparsely settledgeographic areas with few health care alternatives,determining what services can be eliminated isdifficult. Community health centers (CHCs) havetraditionally been a major source of comprehensiveprimary care for the poor, but many CHCs faceincreasing demands for uncompensated care (see ch.5) that may require them, too, to rethink the scope of services they can afford to provide.

q

q

q

g p

could no longer support? Maintaining access-Can local facilities con-tinue to meet their traditional obligations to thepoor and underserved? If so, how? If not, whowill?

Changing mission--Should the hospital orother local health care facility shift some or allof its resources to other services or businessactivities?Facility organization-Should area facilitiescontinue to operate independently or shouldthey engage in cooperative arrangements withother providers? Is the community willing torelinquish any or all control over the delivery of local services?

Washington: Five Health Service Groups

The Washington Rural Health Care Commission,as part of a 1989 report to the State legislature thatexamined ways of maintainingg and improving ac-cess to care for rural residents, identified five levelsof basic health services to reflect the range of serviceresources that should be available in most ruralareas. Basic services are divided into five prioritygroupings (’‘bands’ that represent levels of patientimmediacy or use and complexity of patient condi-tions and care (table 8-l). The five bands are:

–197–


Table 8-l—Basic Health Services for Rural Areas (Washington State)

Band l--prevent death, disability, serious illness24-hour emergency medical services (first

responder/emergency medical technician)

s Stabilization

m Communications

sAir to ground ambulance transport

Essential public health servicessEnvironmental services monitoring and

responsesPersonal health services monitoring and

response

Primary care (e.g., provided by a physician or

midlevel practitioner) including:

sRoutine health maintenance

sPrevention

sCare for acute conditions

8 Prenatal care

Mental healths Crisis intervention

Band2--necessary support services for band 1Diagnostic services

sX-ray: extremities, chest; fluoroscope;ultrasound

qLaboratory: chemistries, urines, blood,

bacteriology

sOther services at same level of complexity

Bad 3--short-term inpatient and home health

Home health servicess Visiting nurse

sMedical services

Selected acute short-term hospital servicessAcute conditions (e.g., pneumonia,

gastroenteritis, and certain accidents)sChildbirth services (level 1)

Selected acute alternative facility servicesa

Band 4--community-based care for chronic conditions

Mental health services

mEvaluationsMental health consultation

sPsychological therapy

Long-term care servicessCommunity-based care (e.g., chore services,

home meals, adult day health)

sSupervised living, boarding housing, respite

cares Skilled and intermediate nursing facilities

Substance abuse and chemical dependencys CounselingsTreatment referral

Band 5-–other services

Dental caresRoutine examination, mechanical cleaning,

fluoridation

Vision and hearing care

Hospice care



and demand Other treatment modalities

NOTE: The first band of services contains the most emergent services as well as those services of greatest

use.

awould be developed through changes in State llCOnSurO standards.

SOURCE: Washington Rural Health Care Commission, A Report to the Legislature on Rural Health Care in theState of Washington (Olympia, WA: January 1989).

1.

2.

3.

4.

5.

This

those services most critical to survival or mostoften utilized (e.g., emergency and primary

care services);basic diagnostic support services;

unessential core of basic acute care and homehealth services;

community-based care for chronic conditions;and

services that help residents in larger populatedrural areas stay within the community for care.

model assumes that, for certain levels of care,providers must use referral arrangements and coop-erative agreements to ensure continued access toneeded services. Only larger rural communitiescould afford to provide services in all five bands.

When assigning services to the bands, the Com-mission applied certain criteria to determine thedegree of urgency and appropriateness for the

service. These included:

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the primacy of preventing death, disability, orserious injury;

the need for immediate diagnosis or treatmentto prevent illness or injury from becoming moreserious and more costly or difficult to treat;the need for medical monitoring to preventdisability or injury;the need to prevent conditions from occurringthat would threaten the health of the generalpopulation;the length of time a health condition can exist

before treatment is needed; andthe physical, psychological, emotional, finan-cial, and time advantages to community andproviders of having certain services locallyavailable (714).

Utah: Basic Needs

The Utah Department of Health has outlined a listof minimum health services that should be available

to small communities in sparsely populated or

Chapter 8-Collaborative Opportunities Between Rural Health Facilities and Government . 199

Table 8-2—Recommended Health Services by Size of Community (Utah)

Population/ Emergency medical Specialtyservice area services Primary care care Hospitalization

Fewer than 500 First responder Intermittent MLP or MD by Referral Referral

persons appointment

Satellite/part-time clinic:

EMT supervision via tele-communication and written

protocol

--------------------------------------------------------------------------------------------------------------

500-900 EMT Full-time MLP or part-time MD Referral or Referral

persons first responder Arrangement for emergency periodic

network in coverage and EMT supervision arrangement inoutlying areas the community

--------------------------------------------------------------------------------------------------------------

900-1,500 EMT Full-time MD or MLP, or Referral or Referral and

persons first responder combination full and part-time periodic infirmarynetwork group practice arrangement in model

Emergency coverage and EMT the community

supervision

--------------------------------------------------------------------------------------------------------------

1,500-4,000+ EMT Small group practice: On-site full-time Small community

persons first responder combination of MD and/or MLP; regularly hospital or

network medical specialists (MD/MLP); scheduled clinic infirmary

IM,PED or OB, CNM as determined within primary referral

by community need; care practice

Emergency coverage and EMT Referral

supervision



p

ABBREVIATIONS: CNM=

certified nurse midwife; EMT= emergency medical technician; IM = internist; MD = medicaldoctor; MLP = midlevel practitioner; OB = obstetrician; PED = pediatrician.

SOURCE: G. Elison, “Frontier Areas: Problems for Delivery of Health Care Services,” Rural Health Care 1,

September/October 1986 (newsletter of the National Rural Health Association, Kansas City, MO).

frontier areas (table 8-2). Its recommendationsspecify that emergency medical personnel would bethe first responders in all small communities, with

regular primary care by a midlevel practitioner orphysician made available in communities of at least500 persons. Specialty care in most small communi-ties would be available only through out-of-areareferral or through arrangements under which out-side providers periodically conduct local clinics. Insome cases, hospital care could be provided incommunities of 1,500 to 4,000 or more persons(183).

CREATION OF ALTERNATIVELYLICENSED FACILITIES IN

RURAL AREAS

Despite their conceptual importance, State at-tempts to define minimum service goals for ruralhealth care have not directly affected rural areas. Afew States have recently begun to intervene more

directly in the structure of basic rural health services

by experimenting with the development of newmodels of health care facilities that require changesin State licensure rules. Most of these alternative

models focus on strengthening underutilized andfinancially unstable small, isolated rural hospitals.Implementation of these models (typically by "down-sizing” existing hospital capacity and services) isintended to ensure access to basic acute and emer-gency care without burdening the facility with therequirements of a full-service hospital.

Efforts to develop alternative delivery models for

rural hospitals have a relatively brief history. In theearly 1970s, the U.S. Department of Health, Educa-tion and Welfare (DHEW)--now the Department of Health and Human Services (DHHS)--permittedabout 150 hospitals to waive the Medicare require-ment that a registered nurse supervisor must be at thehospita1 24 hours a day. Most of these hospitals werein remote areas and served as sole local health careproviders. In 1973, DHEW studied the feasibility of

establishing a new category of “limited service”



Chapter 8--Collaborative Opportunities Between Rural Health Facilities and Government q 201

. institutional liability issues; and

q possible Medicare and Medicaid reimburse-ment schemes and their impact on facilityprofitability (377,524).

In 1989, MHREF, as part of its request for 4-yearfunding of a full MAF demonstration, asked HCFA

to waive: 1) Medicare’s conditions of participationand requirements for prospective reimbursement,and 2) conflict of interest rules that would prohibitPeer Review Organizations (PROS) from helpingMAFs to develop quality assurance programs.

2In

September 1989, HCFA approved continuationfunding of the MAF project for 1 year (377).MHREF expected to receive approval of its waiverrequests in mid-1990, allowing all MAFs to begin

operating by fall of the year (377).

California

In 1988, the California Legislature passed a law(117) granting broad authority to the State Depart-ment of Health Services to study ways to facilitatethe development of new delivery models for ruralhospitals. The Department was given three charges.

i i k h i

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q

q

ing care for up to 96 hours, and patient transferto a hospital if necessary;basic ambulatory care, limited to nonemergentdiagnosis and treatment, minor surgeries re-quiring local anesthesia, and obstetric care forprenatal and postpartum conditions (these serv-ices may be provided through the emergency

service component if they will replicate similarservices already available in the area);basic lab and radiology services, includingsimple urinalyses, blood counts, and basicx-rays; andappropriate support systems such as dietary andpharmaceutical services, and protocols for qual-ity assurance and utilization review.

Model hospitals choosing to provide only the coreservices would face the most lenient facility, staff-ing, and peer review requirements, and they wouldbe expected to show the greatest savings in fixedcosts. As an option, model facilities could supple-ment the required core services with additional,more specialized services to meet the specific needsof their communities. These might include expandedinpatient services (for acute care longer than 96

h ) d d b i d di l i



First, it was to undertake a comprehensive as-sessment of regulatory requirements applicable tosmall and rural hospitals (up to 76 acute-care bedsand located in areas with 15,000 or fewer residents

3).

Second, it was to institute emergency regulationsthat waive or modify existing regulations found to beunreasonably burdensome or inapplicable to ruralhospitals, including licensure requirements. Andthird, it was to conduct pilot projects in small andrural hospitals using alternative rural hospital stand-ards and models.

In accordance with the law, the health departmentis creating a new model design that providesregulatory relief for rural hospitals and is based onlocal needs for an essential, core group of services.These core services include:

. standby emergency medical services, with 24-hour coverage by a physician or midlevelpractitioner;

. basic patient holding and stabilization capacityoffering short-term inpatient medical and nurs-

hours), expanded obstetric and radiology services,and selected inpatient and outpatient surgical serv-ices (427). The level of regulatory oversight wouldincrease with the service scope of the facility.

Guidelines for eligibility currently being consid-ered allow only certain rural acute-care hospitals toparticipate as new model facilities. Eligible hospi-tals would be small (e.g., have an average dailycensus of 10 or fewer acute-care patients) andtypically would be the sole acute-care providers intheir communities. They would maintain their li-censes as hospitals and be encouraged to providesubacute skilled nursing care (with swing beds or adistinct-part skilled nursing facility). Hospitals alsowould have to have the support of their board andmedical staff to participate as a demonstration site,and they would be required to develop a qualityassurance plan (427).

In 1989, three hospitals were initially proposed bythe California Department of Health for designationand demonstration as alternative model facilities.(An estimated 25 sites have been targeted.) Two of

2MHREF has requested that MAFs be paid initially on the basis of reasonable costs (400). Conflict of interest rules do not allow PROS to contractseparately with hospitals to provide support (e.g., assistance with preadmission review) if they are already required to conduct peer review and monitorthe facility’s qurdity of care. MHREF has requested that PROS be allowed to enter into such contracts.

so~er conditions of eligibility ASO exist (~~7).


of time (398,478). Length-of-stay restrictions maybe the most problematic in very remote areas wherealternative sources of care are far away.

Recent National Developments

In 1989, Congress required DHHS (Public Law101-239) to establish a program to provide grants forup to seven States to designate and develop two newtypes of rural hospitals: Essential Access Commu-nity Hospitals (EACHs) and Rural Primary CareHospitals (RPCHs). In addition, up to 15 RPCHsmay be designated in States without EACH pro-grams. EACHs and RPCHs are to forma network of rural health facilities designed to ensure the regional

accessibility and continuity of emergency, primary,acute, and long-term care services. Eligible hospitalsmust be located in States that have or are developinga plan calling for the creation of rural health carenetworks.

To be designated as an EACH facility, a ruralhospital must be more than 35 miles from anotherdesignated EACH or rural referral center, and it musthave at least 75 beds or be located more than 35

il f th h it l 6 EACH ill id

(which does not include physician charges) or acomprehensive cost-based rate (combining facilityand professional services). A prospective paymentsystem must be developed by 1993 for both inpatientand outpatient RPCH services.

States will be responsible for designating and

supporting the development of EACH networks.When designating RPCHs, States that have EACHsmust give preference to hospitals participating inrural health networks. Grants for up to 3 years fromthe Rural Health Care Transition Grants Program(see ch. 3) and the Medicare trust fund will beavailable to help States and hospitals to plan andimplement the EACH/RPCH designations and ruralhealth networks.

The EACH program poses a dilemma for Statesthat are developing their own alternative models forrural facilities. On the one hand, the State-developedmodels can be adapted to the needs of those States.For example, States may wish to:

q

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establish their own minimum mileage limitsbetween designated facilities;establish their own limits on the number of

t b d d th ll d l l f



miles from any other hospital.6 EACHs will provideemergency and medical backup services to desig-nated RPCHs in the network; they must agree toaccept patients transferred from rural physicians andRPCHs, receive and transmit data to RPCHs, andprovide staff privileges to RPCH physicians. EACHswill be considered ‘‘sole community hospitals” forthe purpose of Medicare reimbursement.

RPCHs are smaller facilities that will be requiredto provide 24-hour emergency care; to cease offeringinpatient care except through using a maximum of 6holding beds to stabilize patients for up to 72 hours;and to have patient transfer arrangements with thenearest hospital(s). Rural hospitals becoming RPCHswill be allowed to provide skilled nursing services,and they may use midlevel practitioners with physi-cian oversight. These facilities will not have to meet

existing hospital requirements for 24-hour operation(except emergency care), and the services of dieti-cians, pharmacists, and certain laboratory and radi-ology technicians need only be available on apart-time, off-site basis. Inpatient acute-care serv-ices will initially be reimbursed by Medicare at cost.For outpatient services, RPCHs will at first have theoption of receiving either a cost-based facility fee

q

acute-care beds and the allowed levels of service intensity in model facilities; andconsider criteria for essential access facilitiesother than distance and facility size (e.g.,community income or poverty levels).

On the other hand, States may also find the Federalprogram attractive because it enables RPCHs toreceive Medicare payment—a valuable incentive for

hospitals to shift their emphasis from acute care toemergency and primary care (87).

STATE-PROMOTEDINTEGRATION OF SERVICES

Rather than (or in addition to) adopting a moresweeping approach, some States have focused theirsupport (e.g., technical assistance, regulatory relief)on a few targeted facilities to improve the integrationand accessibility of local health services in specificrural communities. Below are three examples of such initiatives.

North Carolina—The Roanoke Amaranth Com-munity Health Group, a private, nonprofit primarycare practice in rural North Carolina, was estab-

Kl%ese requirements maybe waived by the Seeretary of DHHS.

Chapter 8--Collaborative Opportunities Between Rural Health Facilities and Government .203

home health) are authorized to be provided. Hospi-tals applying for ECH status will receive expeditedreview under Florida’s CON process and may retaintheir hospital license. Regardless of whether theybecome ECHs, the 27 hospitals are also exemptedfrom CON review of home health, hospice, andswing-bed services under the 1989 law. Plans topursue Medicare waivers and implement the ECHlegislation are being delayed until the State decideswhether to apply for participation in the new Federalalternative rural hospital program discussed below.

Wyoming

In 1989, the Wyoming Legislature establishednew licensure and operation regulations for health

care facilities (741). The law introduces the newlicensure category of medical assistance facilities,modeled after Montana’s MAFs, which wouldprovide limited acute care to patients for a period of no more than 60 hours prior to their transfer to ahospital (if transfer is necessary). The medicalassistance facilities must be located more than 30miles from the nearest Wyoming hospital. As inFlorida, regulations that would govern the specific

operation of these facilities have not been estab

establish alternative licensure laws before develop-ing ideas for new delivery models.

Eligibility criteria vary for rural providers seekingto participate as alternative facilities (e.g., they maybe restricted to hospitals or to facilities meeting onlycertain size and location criteria). For example,

Montana’s MAFs must be the only local inpatientcare providers in remote areas. Four of the facilitiesoperating as CCECs in Colorado are CHCs ornursing homes, and all are the sole providers in theircommunities.

States have different ideas on whether a hospitalbecoming an alternative facility should be allowedto keep its existing license to protect against the risk

that its participation as a new facility is unsuccess-

ful. Regulations in Montana require a hospitalbecoming a MAF to give up its acute-care license. InCalifornia, alternative model hospitals would retaintheir acute-care license. Hospitals in Florida thatbecome ECHs but later decide to seek full acute-carerelicensure would receive expedited review andreclassification.

Differences exist among States on the scope of

services to be provided in alternatively licensed



operation of these facilities have not been estab-lished; the period for making these regulatorychanges ends in 1993.

Comparison of State Efforts

Efforts by the above States to develop alterna-tively licensed facilities in rural areas have impor-tant similarities and differences.

To date, only Montana has obtained direct interestand support by HCFA that might lead to waivers of Federal conditions of participation, allowing themodel facilities to receive Medicare and Medicaidreimbursement. However, as noted by differencesbetween the Montana and California projects, theremay be ways to minimize HCFA’s role in suchmatters. The need for waivers will depend in part onthe specific needs and objectives for developing new

models and the extent of regulatory changes in-volved.

The amount of effort that has been invested byStates in developing alternative facility models, aswell as the specificity and flexibility of the lawsdefining and regulating them, varies considerably.Except for California, most States have chosen to

services to be provided in alternatively licensedfacilities, and the role rural providers and communi-ties have in making these decisions. Most of the newmodels allow for use of both physicians andmidlevel practitioners, and most proposals wouldrequire facilities to ensure appropriate transfer andreferral of patients to other providers. Only minimalattention appears to have been given by most States(except Montana) to the effects of new models on

quality of care and patient satisfaction.

Most models that provide for limited inpatientservices in the form of holding and observation careunits use a maximum time standard of 96 hours(Colorado and Wyoming use shorter periods). Exist-ing data suggest that the average acute-care length of stay in a small rural hospital may already closelymatch these proposed limits.

5The maximum l e n g t h

of stay is intended to act as a proxy for serviceintensity and severity of illness. However, someStates (e.g., California) have suggested other meas-ures (e.g., lists of approved admitting diagnoses orservices, composition and skill mix of medicalpersonnel) that might be more appropriate indicatorsof low-intensity care, while giving model facilitiesmore flexibility to hold patients for different periods

% 1985, th e average length of stay for a rural hospital with fewer than 25 beds was 4.9 daY& or about 118 ho~s (236).



Rural communities do not always agree on the bestsolution for their ailing hospitals. In Giddings, Texas,

a recent referendum was passed, despite considerablelocal opposition, that created a tax district to fund

the county hospital.

the hospital district and a special l-year tax levy.Levies for the hospital, to be collected about 8months following the election, were estimated to be$1OO,OOO (379).

Oregon—In 1980, the rural community of Con-don, Oregon, having been without a physician for 2years, sought assistance from the State Office of Rural Health to establish a health service district forsouth Gilliam County. The State granted Condon$20,000 to develop primary care services and assistthe county in the formation of the health servicedistrict. After a brief campaign, voters approved thecreation of the district and a property tax rateexpected to yield 50 percent of the budget of a newprimary care clinic in the first year. Future taxsubsidies were lowered as the clinic began showinga profit (441).

SUMMARY OF FINDINGS

Federal, State, and local governments have under-taken some extraordinary efforts to enable ruralfacilities and communities to preserve or enhancebasic services. At least two States have developedconceptual frameworks for determining an appropri-

ate or minimal set of services and providers for rural



Washington—About 75 percent of Washington’srural hospitals are part of public hospital districts(714). Some of the State’s rural hospitals havesought local tax support both through the establish-ment of hospital districts and the creation of specialtax levies.

Whitman Community Hospital, a county-funded

facility, had been losing money for several years,and in 1986 it requested the county to create a specialtax district to support the facility. The county’scommissioners turned down the request, becauseproperty tax rates were already at their limit man-dated by the State, and a new hospital district wouldreduce amounts for existing special districts (e.g.,fire protection, libraries). A 1987 State law, how-ever, allowed local voters to increase their property

tax rates, fueling again the hospital’s interest topropose the new tax district. In 1988, to easeconcerns from existing districts, the hospital decidedto propose a new district under which it would agreeonly to seek special, temporary tax levies. Theselevies would not be affected by State limits oncurrent property taxes or require existing districts toshare tax monies. In September 1989, following amajor campaign, voters approved the formation of

ate or minimal set of services and providers for ruralcommunities, although thus far these efforts havefound little practical application. Several rural com-munities have enacted new mechanisms for improv-ing local tax support for area health facilities andservices. Some States are offering targeted financialsupport or regulatory relief to a handful of ruralfacilities for improving the local integration of services.

Increasing numbers of States, however, are taking a broader approach: the development of

alternative licensure and delivery models for rural facilities-No collaborative effort between govern-ment and rural facility has been more dramatic thanactivities by a few States to change regulations anddesign new models intended to alter and improve thedelivery of health services in rural areas. Theseefforts reflect differences (and similarities) among

States in the need for structured change in ruralfacilities.

Montana and California have the most developedmodels thus far. Montana’s new MAF licensurecategory alters regulations to allow small, underusedacute-care hospitals to become providers of low-intensity, short-stay acute care. Federal support hashelped develop ideas for demonstrating MAFs.

Chapter 8-Collaborative Opportunities Between Rural Health Facilities and Government q 205

lished in 1976 with technical assistance from theState and funding from the U.S. Public HealthService. The State recently supported research thatfound that the area’s elderly were using post-acutecare resources in distant places near where they hadbeen hospitalized, forcing many to relocate in orderto obtain needed rehabilitation and support services.

To address the need for accessible and comprehen-sive long-term care, the Roanoke Group decided tosponsor the development of a long-term care campusadjacent to the practice.

Development of the long-term care complexbegan with construction of a 60-bed nursing homeand an 18-bed board-and-care facility, which openedin early 1990. Other facilities that have begun

operations are a senior center (supported by a Stategrant) and 20 elderly housing units subsidized by aloan from the U.S. Department of Housing andUrban Development (HUD). Additional plans callfor opening 30 market-rate rental units and anoutpatient rehabilitation clinic.

The State has helped the Roanoke Group over-come several regulatory obstacles during the course

of the project. Technical assistance from the State

State in 1986 appropriated funds to maintain hospi-tal operations for 1 year.

A study of the facility recommended a plan toconvert 10 of the 29 beds from acute care to skillednursing care and improve outpatient services. Theplan would allow the county to operate the facility

ona‘‘breakeven’ basis (in which revenues would atleast equal expenses). Despite pressure from thecounty’s other hospital, the county eventually agreedto accept the State’s restructuring plan. To assist therestructuring process, the State altered Californiaregulations (i.e., approved use of a joint nursingstation for the acute-care and skilled-nursing units,and hospital-based skilled nursing beds for Medi-caid patients). Provisions were made also to cross-

train and certify staff lab and x-ray technicians toreduce standby costs (418).

Florida-The North Central Florida Health Plan-ning Council, a State-funded district health planningagency covering 16 rural counties, assisted in therecent expansion of State-supported primary careservices to indigent populations. The Council real-ized that the increased delivery of such services by

area county health departments was insufficient tomeet many indigent patients’ needs for followup



of the project. Technical assistance from the Statehelped Roanoke receive a CON to build the nursinghome and gain loan approval from HUD to developthe subsidized rental apartments. Efforts byRoanoke to secure a Farmers Home Administration(FmHA) loan to build the 30 market-rate apartmentshave been delayed, however, because of FmHAclaims that no comparable market rate exists fromwhich to make lending decisions. The State is also

providing assistance to help the proposed outpatientclinic become certified as a provider-based ruralhealth clinic (see ch. 3), enhancing the facility’sMedicare and Medicaid reimbursement (418,479).

California—The Mono (County) General Hospi-tal, a 29-bed public facility in rural northernCalifornia, had been suffering annual operatingdeficits of over $300,000 since 1984. After anunsuccessful attempt to have the hospital managedby a multihospital system based 2 hours away, thecounty considered closing the facility. In response toconcerns that closure would severely limit access tobasic health services for area highway travelers, the

area county health departments was insufficient tomeet many indigent patients needs for followupcare. The Council worked with local health depart-ments participating in the State program to establisha referral network of specialists and hospitals, and toset up a centralized Medicaid billing system to beused by participating physicians (222).

LOCAL TAX INITIATIVESIn order to maintain health services, local govern-

ments in many rural areas have increased their taxsupport for public hospitals and other facilities (seech. 5). (In Montana, for example, nearly 60 percentof the nonoperating revenue of the State’s small ruralhospitals in 1985 came from tax funds of localcounties and hospital districts

7(73).) Rural commu-

nities in States with enabling laws can create taxsupport through the establishment of health caredistricts. In addition, some rural facilities may seek local approval of special, temporary tax levies toalleviate immediate financial problems. Two exam-ples of local tax initiatives are described below.

~ospi ta l districts are one type of special district that exist to support a single public function or purpose. Special districts are independent

governmen tal un its tbat have, among oth er thin gs, the autonomou s power to tax. The idea of special districts is not new; by 1982 there were 28,000mtionwide, mainly serving local requirements for schools, water, f~e protectio~ health care, or other needed services (441). Most special districts are

located in rural areas (63 percent in 1977); often they are the only means by which small communities can obtain a critically needed public service (137).





CONTENTSPage

VIABILITY OF FACILITIES AND SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 211FACILITY ADAPTATION TO CHANGES . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . ,.,. 211AVAILABILITY OF SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213COORDINATION AND INTEGRATION OF SERVICES .. .. .. .. .. .. .. .. .. .. ++. +4...... . . 213






and there are no assurances of support from govern-ment or other sources. For example, hospitals inMontana that agreed to become medical assistancefacilities would: 1) serve remote rural communitieswith limited access to care, 2) have to surrender theiracute-care license, and 3) need a waiver of Federalregulations in order to receive Medicare and Medi-

caid payments.

One barrier that must be overcome for these alternative facilities to become viable are inflexible regulations that affect scope of services, staffing,

facility specifications, and other factors. Existinglaws and reimbursement policies now prevent manyfacilities from redesigning their structures andservices to fit local needs and capabilities. The new

Federal initiative creating essential access commu-nity hospitals (EACHs) and rural primary carehospitals (RPCHs) is designed to provide an alterna-tive to some of these regulatory limits on hospitals.Some States, however, may find EACHs/RPCHsless appropriate than State-designed models that aremore attuned to local needs.

Other barriers that may influence the developmentof alternative facilities include:

indefinite support from Federal and State

. regulatory requirements associated with pro-viding hospital-based post-acute and long-termcare (e.g., the requirement that a skilled nursingfacility have its own nursing station).

Hospitals operating at a loss develop poor creditratings, forcing lenders to deny these hospitals

capital to invest in new equipment and facilities fordiversified services. Some providers applying forcertification as rural health clinics have difficultycomplying with certain regulations (e.g., midlevelstaffing). Others experience lengthy waits prior toapproval of participation, delaying their receipt of Medicare and Medicaid payments.

Parochialism, inertia, or lack of planning re-

sources may prevent some facilities from effectively exploring prospects for change. Anecdotalreports suggest that some rural hospital executiveshave been slow to accept and address rapid changesin their financial condition, market, and regulatoryenvironment. Trustees and management often aremindful of community pride in past accomplish-ments and desires to maintain the status quo and areoriented more to service delivery than business

management. In certain cases, this situation may beexacerbated by the lack of dynamic leadership and



indefinite support from Federal and State

governments for planning and technical assis-tance, improved access to capital, and otherforms of financial assistance;

opposition by health care professionals con-cerned about quality of care and protectingtraditional roles and authority; and

questionable acceptance and support from thecommunity, which may believe that inferiorquality care will be provided.

Effective change is stifled by facility financial problems and shortsighted government policies.For example, the increase in outpatient and post-acute care services in most rural hospitals hasbrought these facilities a new source of cost-basedrevenue. However, these new revenue sources are

endangered by:

q

q

increased efforts of hospitals to have theseservices absorb losses accruing from inpatientcare;

current plans by Medicare to pay for ambula-tory surgery and other outpatient services on aprospective basis, which could potentially dis-advantage many rural hospitals; and

access to specialized management and legal counsel.

It appears that rural facilities are either skepticalof the benefits of interinstitutional affiliations orsimply lack the opportunity to participate. Less than15 percent of rural hospitals have joined coopera-tives, and the number in multihospital systems

appears to be declining.To help rural facilities overcome their problems

and implement strategies to adapt to changes,Federal and State governments can intervene in twobroad areas:

q assessing Federal and State regulations and removing those that prevent useful approaches to change, and

. .q providing incentives to States and local com-.

munities to help restructure facilities and

services.

Changes in regulation, however, must assure patientsafety and quality of care. Assessing the impact of new facility models and other strategies on thequality of care should be an explicit component of evaluation efforts.

Chapter 9--Conclusions: Availability of Rural Health Services .213

AVAILABILITY OF SERVICES

Most rural hospitals are within reasonable travel time or distance to another hospital. How-ever, rural hospitals located in more rugged terrain

and in less densely populated regions of theWestern United States are farther apart. Not much

is known about the characteristics and accessibilityof hospitals nearest these facilities. Hospitals inisolated areas are often the only providers of accessible emergency and acute care for widelydispersed populations—yet this role may be im-peded by a lack of physicians and patients. Forexample, frontier hospitals have significantly fewerstaff physicians and acute-care admissions than doother similarly sized rural facilities.

Some financially troubled rural hospitals can nolonger survive as hospitals, due mainly to declininginpatient volume and rising costs of maintainingunderused acute-care capacity. The excessive sup-ply of hospital beds in many rural areas has beencreated by a combination of the prolific hospitalconstruction of the Hill-Burton era, health systemchanges producing more outpatient care, and greater

use of sophisticated technology that cannot beprovided economically in small hospitals.

hospital care in rural areas. In fact, only about 30percent of Medicare-designated SCHs meet currenteligibility criteria. Furthermore, under past paymentrules many SCHs were in poor financial condition,and the value of SCH designation has been question-able to most rural hospitals until recently. Changesin SCH reimbursement (Public Law 101-239) may

improve the financial solvency of many SCHs, butsmaller SCHs (like many small rural hospitals ingeneral) will probably remain financially vulnerabledespite higher Medicare payments. Classification of

sole community hospitals in geographically iso-lated rural areas should more accurately designate

and protect critically needed facilities. Also, be-yond Medicare’s prospective payment system, newsole community provider criteria might: 1) give

special attention to hospitals in rural areas that havea large proportion of low-income or uninsuredresidents, and 2) be expanded to include nonhospitalproviders (e.g., primary care centers, long-term carefacilities).

Travel time to services is an important potentialcriterion for determining when a provider is anessential sole source of local care. But determiningan acceptable standard of travel time or distance tohealth care for residents in remote areas is difficultand controversial Travel guidelines being debated



Those rural hospitals that have closed are

relatively near other hospitals, small in size, and few in proportion to the number of open hospitals.The effects of hospital closures are felt most keenlywhere the hospitals are the only providers of acutecare over large areas. But apparently, few closedhospitals thus far have significantly affected accessto care for local residents. Little is known about thecomparability of open hospitals nearest these closedfacilities in terms of scope and quality of services,geographic and financial accessibility, or opera-tional stability.

There are no well-defined criteria or designations for rural health facilities that: 1) are essential sources of emergency, primary, and acute-care

services for residents geographically isolated orunable to pay; and 2) may need special protection

to maintain the provision of essential services. TheMedicare sole community hospital (SCH) designa-tion was intended to serve this purpose, but as agroup, SCHs no longer represent critical sources of

and controversial. Travel guidelines being debated for application to hospital care in rural areas are overly simplified (e.g., apply to all rural areas and all levels of treatment).

l Most recent studies exam-

ining travel distances have not considered importantaccess issues such as the urgency of the carerequired, the mobility of the patient, and thevariability among facilities in the scope and qualityof services and policies for care to indigent patients.

COORDINATION ANDINTEGRATION OF SERVICES

Health services have developed in response tomyriad factors (including various government poli-cies, programs, and reimbursement mechanisms).Consequently, many services might appear frag-

mented and uncoordinated, particularly for the poorand elderly individuals commonly thought to havethe greatest difficulty in gaining access to healthservices. Hospitals in rural communities generally

have developed and operated independently of other hospitals and area health services. Their lack

IFor ex~ple , ti e 1978 Natio~ Guidelines for Health Plannin g (now repealed) suggested that travel time to a hospital fo r a ~JOri& of residents

of rural areas shoul d be no greater th an 30 min utes (43FR 3056).


of coordination between services can have serious consequences. For example, some rural countyhealth departments in Florida providing primarycare to the indigent have until recently lacked thefunds and planning assistance to arrange necessaryfollowup care with area hospitals and specialists(322).

In other situations, one may find:

q

q

Rural facilities delivering duplicative or under-utilized services-For example, some transpor-tation services to primary care clinics areavailable from various local agencies; how-ever, there may be little coordination or infor-mation on how to obtain these services. Conse-quently, some residents may forego important

care or be prematurely institutionalized be-cause they are unaware of vital services. Rural facilities endangering continuity of care

when referring patients to distant providers—For rural hospitals and physicians not engagedin cooperative transfer and referral arrange-ments with distant providers, ensuring appro-priate and coordinated care for referred patientsis difficult. Also, because of the lack of locally

available care, some rural elderly persons mustbe referred to distant communities for bothh it li ti d t t t i

given scant attention to the development of facilitynetworks. Examples include:

q

q

New delivery models in areas with limited

access—In general, State efforts to create ruralalternative delivery models have only involvedindividual hospitals. No States have considered

developing networks of different types of facilities that improve access to and continuitywithin a more comprehensive set of services.The recent Federal initiative that allows thecreation of EACHs and RPCHs addresses theimportance of rural health care networks;however, it is not clear to what extent nonhospi-tal facilities and providers will be encouragedto have a role in the networks (e.g., only

hospitals are now eligible to become RPCHs).Also, few State models address problems of rural areas with large proportions of low-income or uninsured persons.

The Federal Rural Health Care Transition

Grants Program (see ch. 3) is laudable in itsintent to encourage rural hospitals to adapt tochanges and promote cooperative activity amongfacilities. However, the program lacks the

resources to offer hospitals incentives that areappropriate and adequate for major structural



q

hospitalization and post-acute support services.Thus, some residents relocate and fragment therelationship with their local primary provider.

Rural hospitals having difficulty discharging

patients effectively--Nearly all rural (and urban)hospitals have difficulty finding appropriatepost-acute care for discharged patients (613).

This is a problem in rural communities whereno skilled nursing facility beds or full-servicehome health agencies are conveniently availa-ble.

The lack of effectively coordinated and integrated health services in many rural communitiesunderscores the need for creating new or better

delivery networks of various providers. Currentefforts to improve rural health service delivery have

appropriate and adequate for major structuralchange and long-term solutions. The programwould also be more effective if grant fundswere better prioritized and targeted (e.g., tofacilities and networks in areas with criticalaccess problems).

Many rural facilities are either unaccustomed tocooperative delivery networks or may be lessinclined to participate in networks because of possible government restrictions (e.g., antitrust,antikickback, and tax-exemption rules). An appro-

priate Federal role would be to provide guidelines and incentives for States and local facilities to plan and demonstrate networks. Networks developed inareas with critical access problems may need specialtreatment to ensure their existence.

Part IV

Availability of

Rural Health Personnel





FiguresFigure Page

10-1. Supply of Physicians (MD and DO) by Sex: Estimated 1980 and 1986,Projected 1990 and 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

10-2. Number of Counties Without Selected MD Specialties by Metropolitan/NonmetropolitanStatus, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

10-3. Distribution of Nurse Practitioners by Community Size, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . 251. . . . . . . . . .

10-4. Distribution of Physician Assistants by Community Size, 1989 . . . . . . . . . . . . . . . . . . . . . . . . 25610-5. Employment Status of Registered Nurses in the United States, Selected Years,

1977-1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26010-6. Employed Registered Nurses (RNs) Per 100,000 Residents in the United States by State,

March 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26310-7. Registered Nurses (RNs) and Licensed Practical/Vocational Nurses (LP/VNs)

. . . . . . . . . .

in U.S. Community Hospitals: Total FTEs and FTEs per 100 Patients, 1981 -88 . . . . . . . . . . 26610-8. First Year Enrollment in U.S. Schools of Pharmacy, Academic Years 1969-70

Through 1985 -86 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273

TablesTable Page

10-1. Supply of Physicians (MDs) in the United States, Selected Years, 1963 -88 . . . . . . . . . . . . 21910-2. Supply of Professionally Active Physicians (MDs and DOS) in the United States:

Estimated 1986 and Projected 1990, 2000, 2030 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22110-3. Estimates of Physician Supply, Requirements, and Surplus, 1990 and 2000 . . . . . . . . . . . . 22110-4. Supply of Non-Federal MDs by State, 1980, 1985, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22210-5. Number of Professionally Active MDs Per 100,000 Residents by Region and State:

Estimated 1986 and Projected 1990 and 2000.........,,.. .. .. .. .. .. .+ . . . . . . . . . . . . . . 22410-6. Enrollments and Graduates of Allopathic (MD) and Osteopathic (DO) Medical Schools:

1981-82, 1986-87, and Projected 1991-92 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22510-7. Supply of Active MDs in the United States by Specialty, 1970, 1980, and 1988 . . . . . . . . 22710-8. Professionally ActiveMDs in Primary Care: Rate Per 100,000 Residents and

Distribution by Specialty, 1981 and 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22910 9 N b f P f i ll A i i i C d N i C



10-9. Number of Professionally Active MDs in Primary Care and Nonprimary Care:Estimated 1986 and Projected 2000 and 2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

10-10. American Medical Association (AMA)Projected Changes in Physician Supply andUtilization by Specialty, 1985-2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

10-11. Comparison of Canadian and American Physician Supply for Selected Specialties,1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

10-12. Distribution of MDs by Major Professional Activity, Selected Years, 1970-88 . . . . . . . . . . 232

10-13. Board-Certified Osteopathic Physicians (DOs) by Specialty, 1986...........,..,.. ...23310-14. Distribution of Osteopathic Physicians (DOs) by Geographic Region and State, 1986... 23410-15. Supply of Professionally Active Physicians in Primary Care and Nonprimary Care

by Type of County, 1979 and 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23510-16. Supply of Primary Care MDs by Specialty and Type of County, 1975 and 1988 ...,.... 23610-17. Professionally Active MDs, Primary Care MDs, and DOs per l00,000 Residents in

Metropolitan and Nonmetropolitan Areas by Region and State, 1987/1988 . . . . . . . . . . . . . 23710-18. Physician-To-Population Ratios (1985), Percentage of DOs (1985), and Percent Change in

Ratios (1975-85) in Small Nonmetropolitan Counties, by Region and State . . . . . . . . . . . . 23910-19. Average Number of Hospital Medical Staff in SelectedSpecialties by Hospital Bed Size

and Metropolitan/Nonmetropolitan Status, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24010-20. Average Travel Time to Physicians for Metropolitan and Nonmetropolitan Residents,1983 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

10-21. Average Travel Time to Physicians for Nonmetropolitan Residents by Incomes Above orBelow the Federal Poverty Level, 1983 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

10-22. Number and Resident Population of Nonmetropolitan Counties Without a ProfessionallyActive Physician (MD or DO), 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

10-23. Number and Resident Population of Counties Without a Primary Care MD byType of County,1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....,, . . . . . . 244






Box 10-A—Provider Profile: Physicians

Both allopathic (MD) and osteopathic (DO)physicians undergo 4 years of undergraduate medi-cal training (671). In 1989 there were 126 collegesof allopathic medicine and 15 colleges of osteo-pathic medicine in the United States (673). Allo-pathic schools teach traditional medicine, while

osteopathic schools take a more holistic approachand emphasize the importance of the musculoskel-etal system in the overall health of an individual(148). The curricula in allopathic and osteopathicschools, however, have become more similar overthe years, and the quality of osteopathic physicianshas been increasingly recognized by Federal andother groups (148).

After graduating, allopathic and osteopathic physi-

cians can begin general practice or enter a residencyprogram in their chosen specialty. Residency pro-grams last from 3 to 7 years, depending on thespecialty (673). Graduates of osteopathic schoolscan enter either allopathic or osteopathic residencyprograms, although the vast majority spend theirfirst postgraduate year in an osteopathic internshipas required by the American Osteopathic Associa-tion (673).

On completion of residency training, physicians

can take a certification examination in their medicalspecialty. Compared with approximately one-fourth of osteopathic physicians, most allopathic

physicians by the year 1990 (654). Since theGMENAC report, supply forecasting methodologyand results have been extensively debated andrevised. Table 10-3 compares three alternative setsof projections for the years 1990 and 2000. Recently,the Council on Graduate Medical Education (COGME)reviewed and critiqued various projections andconcluded that, in the aggregate, there is now or soonwill be an oversupply of physicians in the UnitedStates, but that the extent of the oversupply isimpossible to quantify at present (672). It alsoconcluded that the supply of primary care physiciansis in jeopardy, and that expansions in trainingprograms will be needed to prevent future shortages(672).

Despite considerable growth in aggregate physi-

cian supply, there were still 1,944 designatedprimary care Health Manpower Shortage Areas(HMSAs) in 1988, with a resident population of almost 34 million (see table 11-5). An estimated4,104 primary care physicians would have beenrequired to remove these designations. Twenty-ninepercent of all rural residents lived in primary careHMSAs in 1988, compared with 9.2 percent of urbanresidents (see table 11-5).

10

National figures obscure considerable State andregional variations in physician supply. In 1988,



physicians today are board-certified specialists(671).

population ratio7increased by 62 percent over this

period, and it is projected to continue to increasefurther through the year 2020 (table 10-2) (673).

8 9

This growth was largely due to Federal and Stateefforts in the 1960s and early 1970s to combat aperceived physician shortage (129).

In the early 1980s, Federal efforts leveled off afterthe Graduate Medical Education National AdvisoryCommittee (GMENAC) predicted an oversupply of

g p y pp ywhen the national ratio was 229 non-Federal

11MDs

per 100,000 residents, ratios in the States rangedfrom a low of 135 in Mississippi to a high of 349 inMaryland (table 10-4) (39). Not all of these physi-cians provided patient care; the number of MDs indirect patient care per 100,000 residents ranged from

115 in Idaho to 270 in Massachusetts (table 10-4)(39).

Table 10-5 shows projections of the number of active MDs per 100,000 residents in each State,geographic region, and division for 1990 and 2000.In 1986, when the national ratio was 216 per100,000, the East South Central division had the

WDs only.g~ojmt iom i.u table 10-2 include MDs and DOS.

gA~ ~bles ~ t h i s ~~ptm ~tp r e~en tBUeau of He~th~ofessions s u pp l y p~jections reflect the rnedi~ or ‘ ‘basic sefies’ projmtiom, which aSSUllle

that recent trends in enrollments and graduations will continue. For a more detailed description of BHPr’s forecasting meth odology, see the Sixth Report

to the President and Congress on the Status of Health Personnel in the United States (671).

losee Ch. 11 for a de@ed discussion of Federal HMSA designations.

11’ ‘Non-F~~~physiciu5’ excludes ~physicians saltieddirwflyby the Federal Government (i.e., physicians i the mi f i two r i n t h e f i b l i c He~th

Service). It includes National Health Service Corps physicians who are not salaried by the Federal Government. Although the supply of Federal

physicians is important it makes sense to exclude th em from the overall count when looking at availability of ph ysicians to the civilian pop ulation.

Although at one time most National Health Service Corps physicians were Federal employees, most today are not.









Chapter 10--The Supply of Health Personnel in Rural Areas q 225

Table 10-5—Number of Professionally Active MDs Per 100,000 Residents by Region and State:Estimated 1986 and Projected 1990 and 2000—Continued

MDs per 100,000 residents Percent change

1986 1990 2000 1986-1990 1986-2000

Pacific. . . . . . . . . . . . . . . . . . . . 242.7 258.4 280.5 6.2 15.2Alaska . . . . . . . . . . . . . . . . . . 160.5 203.0 244.6 26.2 12.3California. . . . . . . . . . . . . . 250.9 273.8 300.5 8.8 19.5Hawaii. . . . . . . . . . . . . . . . . . 239.9 250.8 270.0

4.2 12.5Oregon. . . . . . . . . . . . . . . . . . 222.3 204.1 209.3 -8.0 -5.7Washington. . . . . . . . . . . . . . 215.7 217.1 231.0 0.5 7.0

U.S. possessions. . . . . . . . . . . . . . 185.2 216.8 275.3 16.7 48.6

alncludes MDS in patient caretresearch, administration, and teaching, and MDs in Federal service. 1986

figures include approximately 90 percent of those MDs not classified according to activity status by the

American Medical Association.bIncludes MDs in the U.S. possessions.

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau ofHealth Professions, Seventh Report to the President and Congress on the Status of Health Personnel

“in the United States, DHHS Pub. No. HRS-P-OD-90-1, (Rockville MD: HRSA, June 1990), table VI-A-16.

Table 10-6-Enrollments and Graduates of Allopathic (MD) and Osteopathic (DO) Medical Schools:1981-82,1986-87, and Projected 1991-92

Percent change

1981-82 1986-87

to to

1981-82 1986-87 1991-92 1986-87 1991-92

MD

First-year enrollments . . . . . 17,871 17,156 16,677 -4.0 -2.8

Graduates . . . . . . . . . . . . . . . . . . 15,985 15,836 16,169 0.9 2.1DO

First-year enrollments. . . . . 1,582 1,724 1,692 9.0 -1.9Graduates. . . . . . . . . . . . . . . . . . 1,017 1,587 1,512 6.0 -4.7



Total

First-year enrollments. . . 19,453 18,880 18,369 -2.9 -2.7Graduates. . . . . . . . . . . . . . . . 17,002 17,481 17,681 2.8 1.1

NOTE: For allopathic and osteopathic schools, first-year enrollments are actual for 1981-82 and 1986-87 andare projected for 1991-92; graduates are actual for 1981-82 and 1986-87 and are projected for 1991-92.

MD first-year enrollments include students transferring from 2-year schools, other degree programs,

and foreign medical schools. DO first-year enrollments and graduates for 1986-87 are preliminary

estimates.

SOURCE: U.S. Department of Health & Human Services, Health Resources and Services Administration, Bureau ofHealth Professions, Seventh Report to the President & Congress on the Status of Health Personnel in

the United States, DHHS Pub. No. HRS-P-OD-90-1 (Rockville, MD: HRSA, June 1990), table VI-A-11.

lowest ratio (161) and New England had the highest the United States (table 10-2) (673). Their growth in(283) (673).

12Although most States may expect an importance is expected to continue into the next

increase in coming years, substantial decreases are century, even though enrollments in both osteo-projected for some (e.g., Colorado, Nevada, and

Wyoming) (673).pathic and allopathic schools are projected to

decrease (table 10-6) (673). The number of osteo-

Doctors of osteopathy (DOs) represent a small but pathic medical schools increased from 5 in 1968increasing proportion of total active physicians in to 15 in 1989 (148).

13As of September 1, 1989,

lzseeapp.FfOralist OfstateSinCIU(ieci in each census region and division.13~e~ae&fi~en~mofo5teopa~cme~~5chw15~wentyem5, and~eww~uent~cre~e~n~e~of~duat~,~not~n~~h~

byanincreaseinthenumberofosteopathic residencytrsiningprograms.As aresul~approximatelyone-halfofosteopathic graduatesseekingresidency

lraining arenowenteringallopathic residencytrainingprograms(148).


there were 27,627 active DOS in the United States(711).

Distribution by Specialty:Primary V. Nonprimary Care

Growth in physician supply has been accompa-nied by a trend towards more specialized practice.The period 1970 to 1988 saw a 68 percent increasein the total number of professionally active MDs, butthe number of MDs in general/family practiceincreased by only 20 percent during this time (table10-7) (39,671). Specialties experiencing the greatestincreases in absolute number during this periodincluded radiology,

14plastic surgery, gastroenterol-

ogy, neurology, pulmonary and cardiovascular spe-cialties, and anesthesiology (39,671).

This trend towards specialization has widened thegap between supplies of primary and nonprimarycare physicians.

15Between 1981 and 1988, MD-to-

population ratios increased more quickly for nonpri-mary care specialists than for primary care physi-cians (table 10-8) (39,672). Furthermore, ratios forfamily/general practitioners showed the smallestincrease (8 percent) of the three primary care

specialties for which information is available (table10-8). The slower rates of increase for primary careMDs in general, and for family and general practition-ers in particular, are projected to continue through

medicine (65). Specialties showing the greatestincreases among male seniors included the pediatricand internal medicine subspecialties, rehabilitationmedicine, and public health (65).

Primary care physicians are almost twice as likelyas nonprimary care physicians to practice in ruralareas. In 1988, 15.9 percent of all professionallyactive primary care physicians (MDs and DOS) werein rural areas, compared with 8.0 percent of activenonprimary care physicians (MDs only) (686).

16The

trend towards nonprimary care will thus have adisproportionately negative effect on rural areas.

The proportion of primary care MDs who areoffice-based has declined as more of these physi-cians enter research, administration, teaching, and

hospital-based positions (68). Rural areas havesuffered more than urban areas from this trend. From1963 to 1986, the ratio of office-based primary careMDs to area residents increased by 2 percent inurban areas but decreased by 8 percent in rural areas(68).

Trends in the Supply of General and

Family PractitionersThe “classic” primary care physician is the

family practitioner (FP). This specialty was firsti d i 1969 i h h bli h f h



ers in particular, are projected to continue throughthe year 2020 (table 10-9) (673). The AMA predictsthat, unlike the supply of other physicians, thesupply of general and family practitioners andgeneral surgeons will not keep pace with growth inthe demand for their services (table 10-10) (369).

A recent study examined data from the 1983 and1987 Association of American Medical CollegesGraduation Questionnaire to determine trends inevolution of specialty choice among allopathicmedical school seniors. During this period, thenumber of seniors indicating a choice for anyprimary care specialty decreased, with the mostdramatic decrease occurring in general internal

recognized in 1969 with the establishment of theAmerican Board of Family Practice (11). Thepredecessors of board-certified FPs were generalpractitioners (GPs), who received no specialtytraining and typically went into practice after 1 year

of graduate internship. GPs still make a significantcontribution to the primary care work force, but theirnumbers have been decreasing. In 1963 there wereover 73,000 GPs in the United States. By 1986, therewere only slightly more than 25,000 GPs, and most(60 percent) were over the age of 55 (11,68). In 1940,approximately 75 percent of physicians in patientcare were GPs (37). By 1970, general and familypractitioners (combined) represented only 19 per-

IA~c l udes diagnostic radiology, therapeutic radiology, radiation oncology, and nUC kU mwcine .

ls~ere is some debate over which specialties should be included as “primary care spaialties. ” While all internists and pediatricians were once

considered primary care specialists, increasing subspec i a l i za t i on in both fields has led researchers and po l i cymake r s to exclude subspec i a l i s t s from the

definition of “primary care.” Some deftitions of prim ary care physicians in clude obstetrics/gynecology and general surgery, since these specialists

often provide substantial amounts of p rimary care, especially when there is a lack of other primary care providers. The Bureau of Health Professionsand the Bureau of Health Care Delivery and Assistance currently include family/general practice, general internal medicine, general pediatrics, and

obstetrics/gynecology in their deftition of primary care physicians for purposes of shortage area designation (see ch. 11). The definition of primary carespecialties used in this report varies depending on the source of information.

16- careh~e includes ~ S in generm~ly practice, gener~ inter~ m~ic ine , gener~ pediatrics, an d obstetrics/~=ology, ~d all DOSin patient care.

Table 10-7-Supply of Active MDs in the United States by Specialty, 1970, 1980, and 19888 b—Continued

Active MDs

1970 1980 1988

Rate per Rate per Rate per Percent change in

100,000 100,000 100,000 in number,

Number residentsc

Number residentsc

Number residentsc

1970-1988

Physical medicine and

rehabilitation. . , . . . . . . . . . 1,479 0.7 2,146 0.9 3,729 1.5 152.1

Psychiatry. . . . . . . . . . . . . . . . . 21,146 10.2 27,481 11.9 33,679 13.6 59.3

Public health . . . . . . . . . . . . . 3,833 1.8 3,126 1.4 3,050 1.2 -20.4

Radiologyh

. . . . . . . . . . . . . . . . 3,360 6.4 20,282 8.8 26,833 10.8 698.6

Other and unspecified. . . . . 19,415 9.3 23,798 10.3 24,779 10.0 27.6

aIncludes Federal MDs and MDs in U.S. possessions. Data for 1988 are as of Jan. 1. Data for 1970 and 1980 are as of Dec. 31.bI

nits publication of 1981 data, the American Medical Association (AMA) began differentiating additional subspecialists in internal

medicine, pediatrics and surgery. Separate estimates were made available for internal medicine subspecialties of allergy and

immunology, diabetes, endocrinology, geriatrics, hematology, immunology, infectious diseases, nephrology, nutrition, oncology and

rheumatology. Separate estimates in pediatrics were provided for the subspecialties of adolescent medicine, neonatal-perinatal

medicine, peiatric endocrinology, pediatric hematology/oncology, and pediatric nephrology. Separate estimates for surgicalsubspecialties were made available for abdominal surgery, cardiovascular surgery, hand surgery, head and neck surgery, pediatric

surgery and traumatic surgery. In this table, these subspecialties were formerly included in AMA published data under internal

medicine, pediatrics and general surgery. When excluded from these categories, the total number of general internists, general

pediatricians, and general surgeons presented for 1988 decrease to 72,038, 34,669, and 32,339, respectively.cRatlos are based on total population plUS CIVlllan population in ‘.S. possessions. 1987 population estimates were used to calculate

1988 MD ratios.dAdjuSted t. include ~S whose addresses were unknown or who were not classified according to sPeclaltY.

eExcludes MDS who were inactive, not classified according to specialty, or whose addresses were unknown.flncludes forensic pathology.

gIncludes general preventive medicine.

‘Includes diagnostic and therapeutic radiology, radiation oncology, and nuclear medicine.iIncludes emergency medicine.

SOURCES: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions,

Sixth Report to the President & Congress on the Status of Health Personnel in the United States, DHHS Pub. No. HRS-P-OD-88-1(Rockville, MD: HRSA, June 1988), table 3-3; American Medical Association, unpublished data, provided by staff at the U.S.

Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions,

Rockville, MD, in 1990.










Table 10-9—Number of Professionally Active MDs in Primary Care and Nonprimary Care:Estimated 1986 and Projected 2000 and 2020 a

Percent change

Specialty 1986 2000 2020 1986-2020

primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . 182,110

General/family practice. . . . . . . . . . . . 71,320General internal medicine. . . . . . . . . . 76,260

General pediatrics. . . . . . . . . . . . . . . . . 34,530

Primary care with

obstetrics/gynecology. . . . . . . . . . . . . . 215,540

Other medical specialties. . ., , . . . . . . . . . . 60,700

Surgical specialties . . . . . . . . . . . . . . . . . . . . 134,440

Other specialties . . . . . . . . . . . . . . . . . . . . . . . 144,530

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521,780

223,920

82,780

94,280

46,860

268,040

99,170

165,550

193,240

681,890

262,010

97,520

111,130

53,360

314,530

115,820

182,770

228,710

789,300

43.9

36.7

45.7

54.5

45.9

90.8

35.9

58.2

51.3%

NOTE: Figures may not add to totals due to rounding.a~nclUdes MDs in Patient care,

research, administration, and teaching, and MDs in Federal service. 1986figures include approximately 90 percent of the physicians who are not classified according to activity

status by the American Medical Association and whose addresses are unknown.bFigures may not add to totals due to rounding.

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau ofHealth Professions, Seventh Report to the President & Congress on the Status of Health Personnel in

the United States, DHHS Pub. No. HRS-P-OD-90-1 (Rockville, MD: HRSA, June 1990), table VI-A-14.

Table 1O-1O--American Medical Association (AMA) Projected Changes in Physician Supply and Utilizationby Specialty, 1985-2000

Difference between

Percent growth, 1985-2000 growth in utilization

S la

Utili tia

d S lb



Supplya

Utilizationa

and Supplyb

All MDsC

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.8% 14.5% 9.3%

General/family practice. . . . . . . . . . . . . . . . . . 9.9 13.0 -3.1

Internal medicine. . . . . . . . . . . . . . . . . . . . . . . . 36.6 24.0 12.6

General internal medicine. . . . . . . . . . . . . 27.0 24.6 2.4

Medical subspecialties. . . . . . . . . . . . . . . . 51.8 23.4 28.4 All surgical specialties. . . . . . . . . . . . . . . . . 13.1 17.0 -3.9

General surgery. . . . . . . . . . . . . . . . . . . . . . . 0.5 16.5 -16.0

Surgical subspecialties. . . . . . . . . . . . . . . 19.9 17.1 2.8

Pediatrics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.8 7.0 31.8Obstetrics/gynecology. . . . . . . . . . . . . . . . . . . . 24.3 2.8 21.5

Psychiatry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.0 19.4 -5.4Emergency medicine. . . . . . . . . . . . . . . . . . . . . . . 69.4 6.2 63.2

aSupply growth estimates based on the projected number of active physicians. Utilization growth estimatesbased on the number of of physician contacts (excluding telephone contacts) as reported in the National

Health Interview Survey and the National Medical Care Utilization and Expenditure Survey.bThls represents the percent growth in utilization (column 2) subtracted from the the Percent growth in suPPly

(column 1).cThe w predicts a 61.1) percent increase in the supply of osteopathic physicians (DOS) between 1986 and 2000.

In 1986, DOS represented 4.2 percent of all physicians--the proportion is expected to increase to 5.5

percent by the year 2000 (table 10-2).

SOURCE: W.D. Marder, P.R. Kletke, A.B. Silberger, et al., physician Sup PIY and Utilization by Specialty:Trends and Projections (Chicago, IL: American Medical Association, 1988), table 8-2.









Active Physiciansa in Primary Care and Nonprimary Care by Type of County, 1979 and 1988 bTable 1O-15--Supply of Professionally

Al l act ive

a

Primary care

c Nonprimary cared

1979 1988 Percent 1979 1988 Percent 1979 1988 Percent

county Rate per Rate per change Rate per Rate per change Rate per Rate per change

classi f icat ion 100,000 100,000 in rate 100,000 100,000 in rate, 100,000 100,000 in rate,

and county size Number population Nu mb e r p o p ul a t i o n 1 9 7 9 - 8 8 N umb e r p o p u l a t i o n Nu mb e r p o p u l a t i o n 1 9 7 9 - 8 8 N u m b e r population N umb e r p o p u l a t i o n 1 9 7 9 - 8 8

1 6 . 1 184,009 107.0

32.2

50.831.716.18.46.74.9

9.5

7.4

89.5

262,843 1 3 8. 5 29.5Metro . . . . . . . . . . . . . . 3 1 2, 5 2 9

No nme t r o . . . . . . . . . . . 4 1, 0 0 2

5 0 , 0 0 0 an d ov e r . . . 1 7 , 9 5 0

2 5 , 0 0 0 t o 4 9, 9 9 9. . 1 3 , 2 6 11 0 , 0 0 0 t o 2 4 , 9 9 9 . . . 7 , 9 2 4

5,000 to 9 , 9 99 . . . . 1 , 5 1 0

2 , 5 0 0 t o 4 , 9 9 9. . . . . . 3 11

F ewe r t h a n 2, 5 0 0. . . . . . 4 6P op u l a t i o n < 1 0 , 0 0 0 :

< = 6 p e r s o n s /

s qu ar e mi l e . . . . . . . . 620>6 p e r s o n s /

s q u a r e mi l e . . . . . . 1 , 2 5 7

U. S . t o t a l . . . . . . . 3 5 3 , 5 3 1

1 8 1. 7 4 2 4 , 1 9 2 225.3 2 4 . 0 1 2 8 , 5 2 0 7 4 . 7 1 6 1 , 3 4 9 86.8

2 2 , 8 7 7 41.4 28.75 3 , 3 3 8 9 6 . 7 2 4 . 1 2 4 , 0 7 0 4 5 . 8 3 0 , 4 6 1 2 0 . 8 1 6 , 9 3 27 8 . 0 55.3

8 , 9 6 3

5 , 4 1 5

2 , 2 3 32 6 6

4 7

8

1 2 , 5 5 8

7 , 0 9 42 , 8 3 0

3 2 1

6 3

11

6 6 . 23 9 . 51 9 . 8

1 0 . 2

9 . 2

6 . 9

30.324.922.621.337.540.1

1 0 1 . 8

7 7 . 5

5 7 . 24 7 . 9

4 4 . 5

2 8 . 2

2 4 , 2 4 91 7 , 1 5 3

9 , 7 6 6

1 , 7 5 9

3 5 95 2

1 2 8. 0

9 5 . 7

6 8 . 3

5 6 . 2

5 2 . 73 2 . 5

2 5 . 8

2 3 . 4

1 9 . 3

1 7 . 1

1 8 . 4

1 5 . 2

8 , 9 8 7

7 , 8 4 65 , 6 9 1

1 , 2 4 42 6 4

3 8

5 1 . 0

4 5 . 9

4 1 . 1

3 9 . 5

3 7 . 82 3 . 3

1 1 , 6 9 1

1 0 , 0 5 9

6 , 9 3 61 , 4 3 8

2 9 6

41

6 1 . 85 6 . 1

4 8 . 5

4 5 . 9

4 3 . 4

2 5 . 6

2 1 . 4

2 2 . 4

1 8 . 1

1 6 . 2

1 5 . 0

9 . 9

1 2 5

2 0 0

2 0 0 , 9 4 1

1 6 3

2 4 1

2 8 5 , 7 2 0

1 2 . 5

8 . 9

1 1 6 . 5

3 1 . 5

2 1 . 6

3 0 . 2

47.0

46.2

157.4

7 8 3

1 , 4 0 8

4 7 7 , 5 3 0

5 9 . 9 27.4

13.0

24.6

495

1,057

152,590

3 7 . 5 6 2 0

3 8 . 9 1 , 1 6 7

6 7 . 9 1 9 1 , 8 1 0

47.4

43.3

79.7

26.4

11.4

17.2

5 2 . 2

1 9 6 . 2

alnc[~es Amerf~an medical Ass~fatj~ ad American osteopathic Associat ion data . I n c ( u d e s p h ys i c i a n s i n r e s ea r c h , a c kn i n i s t r a t i o n, a n d t e a c h i n g , a n d P WS i C i a n S i n F e d e r a L

s e r v i c e .b 1 9 8 8 Mo d a t a a s o f JanO 10 Data f o r 1979 as of Oec. 31.cI~l~es genera~/family practice, interna~ medicine, pediatr ics ,

40 s on~y.

obstetrics/gynecology, and 1987 DO patient care.

e1987 ~W[ation estimtes were u.s.ed to ca~cu[ate 1988 HO and 1987 DO ratios. 1979 population estimates w e r e used t o c a ~ c u ~a t e 1 9 7 9 M D ar d DO r a t i o s .

S U J R C E : R es o u r c e s a n d S e r v i c e s A ci n i n i s t r a t i o n , B ur e a u o f H ea l t h Pr o f e s s i o n s , Of f i c e o f D a t a A n a Ly s i s a n d M a n a g e me n t ,

F i i e S y s t e m p r o v i d e d t o O T A i n 1 9 8 9 a n d 1 9 9 0 .U . S . D e p ar t me n t o f H e a L t h and H u n a n S er v i c e s , H e a L t h

R oc k v i [ L e , MO, u n p ub l i s h e d d a t a f r o m t h e A r e a R e so u r c e








Table 10-17-Professionally Active MDs, Primary Care MDs, and DOS per 100,000 Residents in Metropolitan andNonmetropolitan Areas by Region and State, 1987/1988a-Continued

Total active MDsb

per Total active DOSC

per Primary care MDsd

per

100,000 residents, 1988 100,000 residents, 1987 100,000 residents, 1988

Metro Nonmetro Metro Nonmetro Metro Nonmetro

West. . . . . . . . . . . . . . . . . . . . . . . . 233.5

Mountain. . . . . . . . . . . . . . . . . 213.1

Arizona. . . . . . . . . . . . . . . 220.7

Colorado. . . . . . . . . . . . . . 219.0Idaho . . . . . . . . . . . . . . . . . 172.7

Montana. . . . . . . . . . . . . . . 202.9

Nevada. . . . . . . . . . . . . . . . 169.2New Mexico. . . . . . . . . . . . 250.8

Utah. . . . . . . . . . . . . . . . . . 203.2Wyoming . . . . . . . . . . . . . . . 189.2

Pacific. . . . . . . . . . . . . . . . . . 238.8Alaska

e

. . . . . . . . . . . . . . . 131.0

California. . . . . . . . . . . . 244.2Hawaii. . . . . . . . . . . . . . . . 226.1

Oregon. . . . . . . . . . . . . . . . 229.4

Washington. . . . . . . . . . . . 223.1

114.6

104.8

93.1

112.1106.4

131.9

107.7

94.6

86.4

108.9

128.7

NA

129.5

169.1

124.8

119.9

5.8

12.5

22.6

11.84.1

2.0

7.5

12.3

1.4

0.7

4.1

7.0

3.1

6.7

10.2

7.4

5.6

6.6

9.1

13.44.0

4.6

4.7

7.6

1.6

3.2

4.2

NA

2.8

4.0

4.9

5.5

91.688.1101.6

91.266.960.167.896.170.987.992.569.593.099.2

94,4

90.0

63.961.659.0

72.056.371.1

61.359.249.564.167.2NA

64.8

88.5

66.3

65.2

NOTE: NA = not applicable (see footnote e).apopulation estimates are for 1987.

bIncludes MDs of all specialties in patient care, research, administration, and teaching. American Medical

Association data as of Jan. 1, 1988.

cIncludes DOS of all specialties in patient care, research, administration, and teaching. American OsteopathicAssociation data as of 1987.

‘Includes MD family practitioners, general practitioners, general pediatricians, general internists, andobstetrician/gynecologists .

eFor the purposes of this analysis, Rhode Island and New Jersey were considered to have no nonmetro counties,

and Alaska was considered all one “county” (so the entire population is listed under the “metro” column).

SOURCE: T.C. Ricketts, Rural Health Research Center, University of North Carolina, Chapel Hill, NC. Analysisof unpublished data (provided by the Health Resources and Services Administration) conducted under

contract with the Office of Technology Assessment, 1989.

variations (table 10-18) (.318). The number of physicians (MDs and DOs) per 100 000 residents in

parts. In a 1985 survey, 22 percent of rural residentsreported that they had to travel outside of their



physicians (MDs and DOs) per 100,000 residents insmall rural counties ranged from 39 in the East SouthCentral Region to 75 in the Pacific region, and from31 in Georgia to 86 in California (318).

Rural hospitals have fewer than one-half themedical staff of urban hospitals with a comparablenumber of beds (see table 5-7) (625).

24Rural

hospitals with fewer than 50 beds have roughlyone-third the medical staff of their urban counter-parts. Among rural hospitals, frontier hospitals haveparticularly small medical staffs (625). Table 10-19presents rural-urban differences by hospital sizecategory for each physician specialty.

25

Travel Times to Physicians in Rural Areas

Rural residents travel for longer periods of time toreceive medical care than do their urban counter-

reported that they had to travel outside of theircommunity to receive any kind of medical care(303). Rural residents have longer average traveltimes to every type of physician (table 10-20)(644).

Differences are least for travel to primary carephysicians, especially general practitioners, andgreatest for secondary care physician specialists. Onaverage, for example, a rural resident must traveltwice as long as does an urban resident to visit aneurologist (644).

Among rural residents, those living on farmsgenerally have relatively greater travel times to

physicians (table 10-20) (644). With few exceptions,poor rural residents also have slightly longer traveltimes to physicians than do residents with higherincomes (table 10-21) (644). The exceptions maybedue to physical or financial constraints upon poor

Wncludesbot.hbomd.mtiedandnonbomd.mfiedmdical staff(MDsandDOs).

MphYSic~SpWi~WaSRPfied by eachhospi ta l .








Table 10-20--Average Travel Time to Physicians forMetropolitan and Nonmetropolitan Residents, 1983

Mean travel time (minutes )

Type of Nonmetro

physician Metro All Nonfarm Farm

All physicians . . . . . . . . . . . . . 20

All primary carephysicians . . . . . . . . . . . . . . . 18

General practitioners . . . . . 17

Internists . . . . . . . . . . . . . . . . 21

Pediatricians . . . . . . . . . . . . . 17

Obstetrician/

gynecologists . . . . . . . . . . . . 19

Family practitioners. ...., 16

Osteopaths. ...,..... . . . . . . 14

All secondary care

specialists . . . . . . . . . . . . . . 24

Surgeons . . . . . . . . . . . . . . . . . . 23

Orthopedists . . . . . . . . . . . . . . 24

Ophthalmologists. . . . . . . . . . 25

Neurologists . . . . . . . . . . . . . . 28

Radiologists/oncologists.. 30

Urologists . . . . . . . . . . . . . . . . 23

Dermatologists. . . . . . . . . . . . 20

Proctologists . . . . . . . . . . . . . 22

Otolaryngologists. . . . . . . . . 24

Psychiatrists . . . . . . . . . . . . . 24

Anesthesiologists/pathologists . . . . . . . . . . . . . 20

Other specialists . . . . . . . . . 29

25

20

183223

242016

37

2536

4158

58383454

37

33

73

40

24

20

18

3223

23

20

16

36

25

35

39

58

48

36

34

54

37

33

73

40

35

26

23

36

31

36*

17

57

22

46

70*

86

59

27*

31*

*

60

NOTE: Not all metro areas are included. Sample siz-

es in some cases may be very small. S t a t i s -

t i c a l s i g ni f i c a n c e of differences in times

cannot be calculated. Asterisks (“*”)

indicate that no one in the sample met the

specifications for that entry.

than 25,000 residents, and 166 were counties withfewer than 10,000 residents. Well over one-half were frontier counties. Among MDs, general/familypractitioners are the most ubiquitous specialists;they were present in all but 205 rural counties and allbut 2 urban counties (figure 10-2)(686).

Changes in Rural and Urban Physician Supply

Federal policies regarding health personnel havebeen influenced not only by GMENAC’s projectionsof increases in supply but also by three RAND Corp.studies conducted in the early 1980s which sug-gested that overall growth in physician supply wouldin time solve the problem of geographic maldistribu-tion of physicians.

All three studies examined changes in the supplyof physicians in towns with populations of 2,500 andmore during the 1960s and 1970s. The first study(550) found that the number of board-certifiedspecialists per capita increased more in smallertowns than in larger towns. The second (436) foundthat by 1979, nearly every town of more than 2,500residents had ready access to a physician. The third(727) found that 96 percent of towns with a

population of at least 2,500 were fewer than 10 milesaway from a physician and that 98 percent of theU.S. population lived within 25 miles of a general orfamily practitioner. These three studies, however,had some limitations: they excluded towns withfewer than 2,500 residents, the results were domi-




vices, Centers for Disease Control, Nat-

ional Center for Health Statistics, Hyatt-

sville, MD, unpublished travel time data

from the 1983 National Health InterviewSurvey provided by E. Parsons, May 1989.

rural residents to visit the physician closest to theirhomes.

Counties With No Physicians

In 1988, 111 rural counties (with an aggregateresident population of 325,100) had no physician atall (table 10-22) (511). These counties are concen-trated in the West North Central, South Atlantic,West South Central, and Mountain census divisions.

More detailed data are available for MDs alone.In1988, 176 counties (with a total resident populationof 713,700) had no primary care MD (table 10-23)(686). All of these were rural counties with fewer

fewer than 2,500 residents, the results were dominated by findings in towns with more than 10,000residents, and they excluded DOS and Federalphysicians (318).

From these three studies policymakers concludedthat market forces play a significant role in thedistribution pattern of physicians, and that a greatersupply of physicians in a particular specialty willlead to a greater diffusion of those specialists intorural areas. In the wake of RAND and GMENACstudies, Federal efforts to improve the geographicdistribution of health personnel decreased signifi-

cantly (68,318,462). However, more recent Stateand national studies have found that increases innational supply have not consistently producedcorresponding increases in rural supply, particularlyin small or isolated rural areas, and that rural/urbandisparities in overall physician supply have actuallywidened during the past two decades. Summaries of

the studies follow.

Chapter 10-The Supply of Health Personnel in Rural Areas q 243

Table 10-21-Average Travel Time to Physicians for Nonmetropolitan Residents by IncomesAbove or Below the Federal Poverty Level, 1983

Mean travel time (minutes )

Above Below IncomeType of physician All nonmetro Poverty Level Poverty Level Unknown

All physicians. . . . . . . . . . . . . . . . . . . . . . . . . . . 25 24 25 29

All primary care physicians. . . . . . . . . . . . . . 20 20 22 21

General practitioners. . . . . . . . . . . . . . . . . . . 18 17 22 18Internists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 31 35 42Pediatricians. . . . . . . . . . . . . . . . . . . . . . . . . . . 23 22 28 26Obstetrician/gynecologists . . . . . . . . . . . . . . 24 25 15 33Family practitioners. . . . . . . . . . . . . . . . . . . . 20 20 * 20Osteopaths. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 17 15 2

All secondary care specialists. . . . . . . . . . . 37 36 39 46

Surgeons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 24 32 30Orthopedists. . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 36 38 28Ophthalmologists. . . . . . . . . . . . . . . . . . . . . . . . 41 38 53 70Neurologists. . . . . . . . . . . . . . . . . . . . . , . . . . . . 58 65 46 27Radiologists/oncologists . . . . . . . . . . . . . . . . 58 57 25 64Urologists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 35 45 62Dermatologists. . . . . . . . . . . . . . . . . . . . . . . . . . 34 33 30 40Proctologists. . . . . . . . . . . . . . . . . . . . . . . . . . . 54 54 * *

Otolaryngologists. . . . . . . . . . . . . . . . . . . . . . . 37 35 51 44Psychiatrists. . . . . . . . . . . . . . . . . . . . . . . . . . . 33 35 43 14Anesthesiologists/pathologists . . . . . . . . . . 73 25 * 120Other specialists. . . . . . . . . . . . . . . . . . . . . . . 40 41 13 47

NOTE: Sample sizes in some cases may be very small. Statistical significance of differences in times cannotbe calculated. Asterisks (I’*”) indicate that no one in the sample met the specifications for that

entry.

SOURCE: U.S. Department of Health and Human Services, Centers for Disease control, National Center for Health

Statistics, Hyattsville, MD, unpublished travel time data from the 1983 National Health InterviewSurvey provided by E. Parsons, May 1989.

National Studies Examining Change in Rural Physician Supply A Bureau of Health Professions

young physicians or had lost some. The Northernd W t i h d th t tt ti



Physician Supply—A Bureau of Health Professions(BHPr) study found that during the 1970s, thegreatest improvement in the number of patient care

and office-based primary care physicians per capitaoccurred in large (more than 25,000 residents) ruralcounties and small urban counties, with the smallerrural counties experiencing comparatively smallincreases (683). A study of physician distributiontrends between 1950 and 1978 singled out thosecounties with the smallest populations and thepoorest physician-to-population ratios as those withthe least improvement in supply (205). A study of

changes in physician supply in individual ruralcommunities between 1971 and 1981 found that alarge number of these communities did not experi-ence increases in physician supply, and that someeven experienced decreases (738).

A study of young physicians settling in rural areasbetween 1975 and 1979 (332) found that 60 percentof all rural counties had either not attracted any new

and Western regions had the most success attractingyoung physicians, while the Central region had theleast success. A later study found that in 1983,31

percent of the least populated as compared with 92percent of the most populated rural counties hadgained at least one young graduate (334). This studyconcluded that physicians tend to locate in larger,more attractive rural communities, and that lessattractive communities have difficulty attractingphysicians without special targeted efforts.

More recent BHPr data indicate that relatively

slow increases in physician supply in small ruralcounties have continued through the 1980s. From1979 to 1988, the number of office-based MDs per100,000 residents rose 18 percent in rural counties of fewer than 10,000 residents compared with 23percent in all rural counties and 25 percent in urbancounties; the corresponding increases for all patientcare MDs were 17, 24, and 24 percent (table 10-24)(686). In 1988, the incidence of patient-care MDs in






Table 10-24-Total MDs, Patient Care MDs, and Office-Based MDs Per 100,000 Residents by Type of County,1979 and 1988a

County classification Percent change,

and county population 1979 1988 1975-88

Total MDs per 100.000 residents

Metro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219.3 262.6

Nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87.2 108.5

50,000 and over. . . . . . . . . . . . . . . . . . . 116.3 146.725,000-49,999. . . . . . . . . . . . . . . . . . . . . 86.8 106.2

10,000-24, 999. . . . . . . . . . . . . . . . . . . . . 62.0 74.7

0-9,999. . . . . . . . . . . . . . . . . . . . . . . . . . . 48.6 58.2

U.S. total . . . . . . . . . . . . . . . . . . . . . . . . . 188.4 227.7

Patient care MDs per 100,000 residentsb

Metro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174.3 215.6

Nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73.3 90.5

50,000 and over. . . . . . . . . . . . . . . . . . . 97.5 122.2

25,000-49,999. . . . . . . . . . . . . . . . . . . . . 73.3 89.9

10,000-24,999. . . . . . . . . . . . . . . . . . . . . 52.0 61.3

o-9,999. . . . . . . . . . . . . . . . . . . . . . . . . . . 40.5 47.5

U.S. total . . . . . . . . . . . . . . . . . . . . . . . . . 150.7 187.2

Office-based MDs per 100,000 residentsb

Metro.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.5 153.8

Nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65.6 80.6

50,000 and over. . . . . . . . . . . . . . . . . . . 85.9 107.0

25,000-49,999. . . . . . . . . . . . . . . . . . . . . 66.4 81.3

10,000-24,999. . . . . . . . . . . . . . . . . . . . . 46.7 54.9

o-9,999. . . . . . . . . . . . . . . . . . . . . . . . . . . 37.4 44.1

U.S. total . . . . . . . . . . . . . . . . . . . . . . . . . 110.0 137.2

19.7

24.4

26.122.4

20.5

19.6

20.9

23.7

23.5

25.3

22.617.9

17.4

24.3

24.5

22.9

24.6

22.3

17.5

17.7

24.8

am data for 1988 are as of Jan. 1.b

Prior to 1988, data are as of Dec. 31.

1987 population estimates were used to calculate 1988 MD ratios. Prior to 1988, population estimates usedwere for the same year as MD data.

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of

Health Professions, Office of Data Analysis and Management, Rockville, MD, unpublished data from the Area Resource File system provided to OTA in 1989 and 1990.



percent) than in all urban counties (27 percent), butincreased very little (9 percent)

27in small rural

counties (table 10-25) (318).

State Studies Examining Changes in Rural Physician Supply—Several State studies lend sup-port to the findings of the national studies mentionedabove:

. In Pennsylvania, overall physician-to-population

ratios increased by 25 percent in rural and 32percent in urban counties from 1970 to 1980.28

Ratios for general and family practitioners

actually dropped during this period for ruraland urban counties alike (145).

29

. In Minnesota, the primary care30

physician-to-population ratio increased by 63 percent inurban counties from 1965 to 1985, but actuallydecreased by 2 percent in rural counties. Theratios of other specialists increased in smallercommunities, however, and these physiciansmay actually be providing a substantial amountof primary care (164).

q

In Georgia, physician-to-population ratios in-creased slightly more in rural areas (28 percent)than in urban areas (24 percent) between 1968

zT~c.r~W~g.Tp~ent with MDson ly , and9.4 percent when DOswe r e included.

~Thisanalysi5 includedMDsandDC)s.

%sanalysisdidnotincludeDOs.

% this study, “primary care” included general/family pmctice, pediatrics (includin g subspecialties), and internal medicine (includingsubspecialties).






Table 10-28-Practice Location Preferences of Allopathic Medical School Seniors, 1979 and 1989 a

Setting where student would most like to Percent of seniorspractice upon completion of medical training

b

1979 1989

Large and moderate sized cities and suburbs . . . . . . . . . . . . . . . . . . . . . . . . . .59.1Large city (more than 500,000 residents). . . . . . . . . . . . . . . . . . . . . . . . . . .17.2Suburb of large city. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1City of moderate size (50,000 to 500,000 residents). . . . . . . . . . . . . . . .25.4

Suburb of moderate size city. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4Small city or town (not a suburb). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26.6

Small city (10,000 to 50,000 residents--other than suburb). . . . . . . . . 18.5Town (2,500 to 10,000 residents--other than suburb). . . . . . . . . . . . . . . . 8.1

Small town or rural area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2Small town (fewer than 2,500 residents). . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8Rural/unincorporated area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4

Undecided or no preference. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.0No response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5

TotalC

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0

79.523.717.429.9

8.512.0

9.1

2.9

1.5

0.7

0.8

6.5 NA 0.4

100.0

NOTE: NA =not applicable.aReflects preferences indicated by allopathic medical school seniors on a graduation questionnaire.In 1979,8,382 seniors (or 55 percent of all final year students) completed the questionnaire.In 1989, 11,175students (or 72 percent of all final year students) completed the questionnaire.

bDoes not reflect metro or nonmetro status of area.cPercentages may not add to 100 due to rounding.

SOURCES: Association of American Medical Colleges, 1979 Medical Student Graduation Questionnaire Survey:Sumna ry Revert for All Schools (Washington, DC: Association of American Medical Colleges, 1979);

Association of American Medical Colleges 1989 Graduate Questionnaire Results: All School Smary

(Washington, DC: Association of American Medical Colleges, 1989).

medicine in their current geographic area during thenext few years, compared with 74 percent of physicians Statewide and 79 percent of physicians inthe Twin Cities metro area (173).

Location Choices of New Medical Graduates—Allopathic medical school graduates are increas-

(see box 10-B) have played valuable roles inproviding primary health care services traditionallyprovided by physicians. Often referred to collec-tively as “midlevel practitioners” (MLPs), thesethree professional groups have developed rapidlysince the 1960s in response to concerns over



Allopathic medical school graduates are increasingly expressing a reluctance to choose rural prac-tice. In 1979, 27 percent of allopathic medical school

seniors preferred to practice in a small city or largertown, and 3 percent preferred small towns or ruralareas (table 10-28) (58). By 1989, these proportionshad dropped to 12 percent and 1.5 percent, respec-tively (table 10-28) (61). Osteopathic physiciansseem to have a markedly greater inclination towardsrural practice than do allopaths. In 1988,21 percentof senior osteopathic medical students reported thatthey intended to practice in communities of l0,000

to 50,000 people, and 9 percent intended to practicein communities of fewer than l0,000 people (21).

MIDLEVEL PRACTITIONERS

Nurse practitioners (NPs), certified nurse-midwives (CNMs), and physician assistants (PAs)

pgeographic maldistribution of primary care provid-

ers. Although MLPs can substitute for physicians in

many instances in the delivery of primary medicalcare, their scope of practice is more limited. Statemedical and nurse practice laws that regulate theseprofessions require some degree of physician super-vision or collaboration. Within their areas of compe-tence, MLPs provide care whose quality is equiva-lent to that of care provided by physicians, and theyoften do so at a comparatively low cost (617). NPsand, to a lesser extent, PAs see fewer patients andspend more time with each patient than do physi-cians, presumably because NPs provide nonmedicalservices such as counseling and health educationduring a patient visit (617). Notwithstanding thequality and cost-effectiveness of MLP care, lack of direct third-party coverage for MLP services has


Box 10-B—Provider Profiles: Midlevel Practitioners

Nurse Practitioners (NPs)

The NP profession developed during the 1960s in response to concerns over a shortage of physicians (617).NPs are registered nurses who have completed advanced training programs in primary health care delivery. Theseprograms grant either certificates or master’s degrees and involve from 9 months to 2 years of full-time study.Functions performed by NPs include health assessment, physical examinations, management of minor acute andchronic illnesses, development of plans of care, patient education and counseling, health promotion and disease

prevention activities, and coordination of health care services. In some States they have the authority to prescribemedication. NPs can manage patients independently of physicians, but they do so within the context of a systemthat allows for professional consultation, collaborative management, and, when appropriate, referral (617).

Physician Assistants (PAs)

The PA profession also developed during the 1960s in response to concerns over a shortage of physicians(617,671). PAs work with or under the supervision of physicians, providing diagnostic and therapeutic patient care.They take patient histories, perform physical examinations and basic diagnostic tests, develop treatment plans,counsel patients on preventive health behavior, and facilitate referrals to other health or social service facilities(671). In some States, they have the authority to prescribe certain medications (192). PA training programs provide

an average of 50 weeks education in the basic medical sciences and another 52 weeks in various clinical disciplines,including approximately 34 weeks of supervised primary care clinical experience and approximately 19 weeks inthe nonprimary care specialties. Most PA programs grant either bachelor’s or associate degrees, depending on theprogram structure and the educational background of the student (192). A small but increasing number of PAprograms are now granting master’s degrees ((67.3). While NPs and CNMs perform both nursing and primarymedical care tasks, PAs perform medical tasks exclusively (192).

Certified Nurse-Midwives (CNMs)

Trained nurse-midwives were introduced into the United States with the establishment of the Frontier NursingService in rural Kentucky in 1925. The first formal training program opened in 1931 (24). A CNM is educated in

the two disciplines of nursing and midwifery. CNMs provide gynecological care, family planning, and prenatal care.They also deliver babies, co-manage high-risk pregnancies with physicians, and care for mothers and infants afterpregnancy (24,617). Programs preparing CNMs offer either certificates or master’s degrees (24). Like NPs, CNMscan practice independently of physicians, but only within a context that provides for consultation, collaborativemanagement, and referral (24).

Certified Registered Nurse Anesthetists (CRNAs)

CRNAs are baccalaureate-prepared registered nurses who have completed an additional 24 to 36 months



CRNAs are baccalaureate prepared registered nurses who have completed an additional 24 to 36 monthstraining in anesthesiology in an accredited program and have passed a national certification examination in thespecialty (522). CRNAs substitute for anesthesiologists across States and across a wide range of procedures.

Licensure and certification laws require that CRNAs work under physician supervision, but direct supervision byan anesthesiologist is generally not required (522).

resulted in these practitioners’ not being used to theirfullest potential (617).

This section examines the supply and geographic

distribution of each type of MLP. Also included aresupply and distributional data for certified registerednurse anesthetists (CRNAs), who often substitute foranesthesiologists in rural facilities (see box 10-B).Studies comparing anesthesia outcomes by providertype have found no significant differences betweenCRNA and MD anesthesiologist-administered serv-ices (75,200,211).

Nurse Practitioners

National Supply

In 1988, there were in the United States anestimated 56,043 RNs who had completed formaltraining as NPs (511). Only 20,649 RNs, however,were employed with the position title of nursepractitioner, including 2,318 who had not completedformal training (511). NPs are employed primarilyin ambulatory care settings (about 33 percent) andcommunity and public health settings (about 30




Table 10-29—Characteristics of Practicing Nurses Practitioners (NPs) by Community Population Size, 1988a

Community population

Fewer than 1,000 1,000 to 50,000 More than

residents residents 50,000 residents

[N = 1,22] [N = 1,771] [N = 3,884]

Percent of NPs:Specialty:

Family health. . . . . . . . . . . . . . . . . . . . . . .Adult health . . . . . . . . . . . . . . . . . . . . . . . .

Pediatric health . . . . . . . . . . . . . . . . . . . .

Gerontologic health . . . . . . . . . . . . . . . . .

School/college health . . . . . . . . . . . . . . .

Women’s health. . . . . . . . . . . . . . . . . . . . . .Psychiatric/mental health. . . . . . . . . . .

Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Education:

Masters degree or greater. . . . . . . . . . .

Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Employment setting:

Private practice (with &

without a physician) . . . . . . . . . . . . .

HMO....., . . . . . . . . . . . . . . . . . . . . . . . . . . .

Freestanding

primary care clinic. . . . . . . . . . . . . .

Hospital outpatient clinic. . . . . . . . . .

Public health clinic. . . . . . . . . . . . . . . .

Hospital inpatient unit. . . . . . . . . . . . .

Extended care facility. . . . . . . . . . . . . .

School/college. . . . . . . . . . . . . . . . . . . . . .Occupational health. . . . . . . . . . . . . . . . .

Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total.. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other characteristics:

Percent of NPs having

hospital privileges. . . . . . . . . . . . . .

Percent of NPs having

nursing home privileges. . . . . . . . . .

59.83.3

12.3

3.3

2.5

5.7

0.0

13.1

100.0

32.810.8

18.8

1.9

4.4

19.3

1.9

10.1

100.0

20.117.4

18.1

3.3

4.3

18.0

2.9

15.9

100.0

33.8 33.2 52.4

66.2 66.8 47.6

100.0 100.0 100.0

9.20.8

47.5

3.3

7.5

2.5

2.5

5.02.5

18.3

100.0

20.8

3.0

16.8

4.5

18.1

6.5

1.5

11.72.9

13.6

100.0

14.5

10.4

11.7

13.7

7.9

8.6

1.7

11.72.8

16.2

100.0

27.5 26.1 26.0

9.8 8.6 3.9



s g p g s

Percent of NPs caring

for patients over age 65. . . . . . . . .

9.8 8.6 3.9

76.9 56.4 50.1

acomunity population size was self-reported and self-defined. It does not reflect metro or nonmetro location.

SOURCE: American Academy of Nurse Practitioners, Lowell, MA, unpublished data from the 1988 Nurse Prac-

titioner Survey.

and NPs in the largest communities are more likely Approximately 80 percent of these PAs were in-to be found in private practices or hospital outpatient volved inpatient care (671). The distribution of PAsclinics. Approximately one-third of NPs in the by State is closely linked to the presence of PAsmaller communities have a master’s or doctoral training programs (table 10-30)(62,671). Dramaticdegree, compared with over one-half of those in the differences in estimated PA population exist amonglargest communities (l3). States, ranging from 2,508 PAs in California to only

Physician Assistants 35 in Delaware. The East South Central had thelowest regional PA population (648 PAs) in 1987,

National Supply while the Middle Atlantic had the highest (3,793

In 1987, there were an estimated 19,446 PAs PAs) (62,671). PA distribution may also be influ-

licensed to practice in the United States, an increase enced by State laws and regulations regarding PAs’

of 15 percent over only 2 years earlier (671). scope of practice. In some States, PAs are required








Figure 10-4-Distribution of Physician Assistantsby Community Size, 1989a

11%aRepreSents ltijon of PAs’ major praetiee setting. Based on 1,588

responses to a 1989 sample survey of PAs. Community size wasselfdefinsd and self-reported, and does not reflect metrohonmetroIoeation.

%he actual percentage (24.62) was rounded to 24 pereent for the purpose

of this figure.SOURCE: Office of Technology Assessment, 1990. Data from Ameriean

Academy of Physician Assistants, Alexandria, VA, unpublisheddata from the 1989 PA Prescriptive Praetiee Survey.

PAs in large cities (more than 250,000 residents)employed mostly in other medical and surgicalsubspecialties (17). More small community andsmall city PAs than large city PAs were in solopractice settings, and fewer were in group practice,

hospital, and HMO settings. PAs in small communi-ties were considerably older, were more likely to bemale, had lower salaries, and tended to have been intheir current employment setting much longer thanPAs in small and large cities. Small community PAswere also less likely than PAs in small and largecities to have at least a bachelor’s degree (17).

who were not (681). Almost one-fourth of CNMsresponding to the 1988 ACNM survey were em-ployed by hospitals (342). Seventeen percent wereemployed by physicians, and 9 percent were em-ployed by other CNMs or were in private practice(342). Twenty-five nurse-midwifery education pro-grams were in operation in the United States at theend of 1987 (24).

Studies have shown that CNMs can managenormal pregnancies at least as well as physicians(169,359,502,504,565). Numerous factors, includ-ing lack of physician acceptance, liability coveragecosts and availability, and reimbursement coverage,have influenced the characteristics and location of CNM practice.

Rural Supply

Although no information regarding the nationalrural/urban distribution of CNMs is available, sur-vey data show that the proportion of CNMs insmaller communities has decreased in recent years.The proportion of active CNMs practicing in com-munities of fewer than 50,000 residents decreasedby over 10 percentage points in both small (fewer

than 10,000 residents) and mid-sized (10,000 to49,999 residents) communities between 1982 and1987 (table 10-33) (23a,26).

42

State data indicate that the distribution andactivity of CNMs vary considerably between ruraland

q

urban areas.

In Arizona, in 1987, although only one-half of



Certified Nurse-Midwives

National Supply

As of January 1990, 4,260 nurse-midwives hadbeen certified by the American College of Nurse-Midwives (ACNM) (27), a 67 percent increase overthe number in 1982 (2,550) (23a) .41 Seventy-onepercent of all CNMs responding to a 1988 ACNMsurvey were practicing nurse-midwifery (342). TheDivision of Nursing estimates that there were some

2,886 practicing nurse-midwives in the UnitedStates in 1988, but it does not distinguish betweenthose who were certified by the ACNM and those

q

q

g yCNMs in urban counties were practicing mid-

wifery, all of the 21 CNMs in rural countieswere delivering babies. CNMs attended 4percent of all deliveries in Arizona in 1985, andin some rural counties they delivered more than50 percent of the total county births (220).

43

In Texas, in 1986,22 percent of the 79 CNMspracticing nurse-midwifery were practicing inrural counties (708).

In Utah, in 1986, only 1 of the 42 known

employed CNMs was practicing in a ruralcounty. Only one rural hospital in Utah granteddelivery privileges to nurse-midwives in 1987,

dlr)~~~~~~geo~p~c distribution~d c~cteristics of C NM S wer e availa ble for 1982, 1987, and 1988,basedon - ey s conduct~by ~ e A ~ .

The ACNM is the only mtionsl certifying body for nurse-midwives.

4%ee footnote 36.

&Mo ~ t _ del ivefig bab i e5 fi ~ Mona co~ties work on ~di~ reservation and ~e employed by the Indian Health Service (221).


Table 10-33-Distribution of Practicing Certified Nurse-Midwives (CNMs) by Community Population Size,

1982 and 1987a b

Table 10-34--Number of Nurse Anesthetist TrainingPrograms and Graduates, 1976-90

1982 1987

Community population (N=l,065) (N=l,526)

Fewer than 10,000 . . . . . . . . . . . . 8 .7% 7 .9%

10,000 to 49,999 . . . . . . . . . . . . . 14.5 13.7

50,000 to 199,999. . . . . . . . . . . . 17.4 20.0200,000 to 499,999. . . . . . . . . . . 13.2 10.6

500,000 or more. . . . . . . . . . . . . . 40.6 39.0

Totald

. . . . . . . . . . . . . . . . . . . . . 100.0 100.0

aRepresents community population size ‘fCNMS’

b primary work site.

Data are based on the 1982 and 1987 American Collegeof Nurse-Midwives (ACNM) Surveys and only reflectcharacteristics of nurse-midwives who are certifiedaccording to the requirements of the ACNM. Data for

1982 are based on responses from 1,684 CNMS (66% ofall CNMS in 1982). Data for 1987 are based onresponses from 2,278 CNMS (57% of all CNMS in1987). CNMS who were residing outside of the United

States, were not practicing nurse-midwifery, or did

not indicate the size of their primary worksite are

excluded.cDoes not reflect metro or nometro location.

‘Percentages may not add to 100 due to rounding.

SOURCE: American College of Nurse-Midwives, Nurse-

Midwifery in the United States: 1982 (Wash-

ington, DC: ACNM, 1984); American College

of Nurse-Midwives, Washington, DC, unpub-lished data from the 1987 five-year survey

provided to OTA in 1990.

and CNMs in the State do not participate inhome deliveries (158).

Certified Registered Nurse Anesthetists(CRNAs)

Total number Total number

Year of graduates of programs

1976. . . . . . . . . . . . . . . .

1977. . . . . . . . . . . . . . . .

1978. . . . . . . . . . . . . . . .

1979. . . . . . . . . . . . . . . .

1980. . . . . . . . . . . . . . . .1981. . . . . . . . . . . . . . . .

1982. . . . . . . . . . . . . . . .

1983. . . . . . . . . . . . . . . .

1984. . . . . . . . . . . . . . . .

1985. . . . . . . . . . . . . . . .

1986. . . . . . . . . . . . . . . .

1987. . . . . . . . . . . . . . . .

1988. . . . . . . . . . . . . . . .

1989. . . . . . . . . . . . . . . .

1990. . . . . . . . . . . . . . . .

1,094

1,029

1,063

1,078

1,0231,055

1,107

985

953

722

722

720

574

636

693a

194

166

172

163

161148

142

137

127

112

104

99

84

8080

b

‘Projected.bNtier of Progr=s as of Apr. 1, 1990.

SOURCE: American Association of Nurse Anesthetists,

Chicago, IL, unpublished data provided to

OTA in April 1990.

withdrawal of anesthesiologist support and concernswithin hospitals over program costs (522). Thenumber of graduates has increased since 1988,

reaching a projected 693 in 1990, but it is still farbelow the peak level of 1982 (table 10-34)(22).

The distribution of CRNAs and anesthesiologistsby State is shown in table 10-35, which ranks theStates by their CRNA-to-population ratio. The sevenStates with average rates at or above the nationalmedian for both providers all have both large



Certified Registered Nurse Anesthetists(CRNAs)

In 1986, there were 22,500 CRNAs and 19,000anesthesiologists in the United States, but thenumber of anesthesiologists has increased muchmore quickly than that of CRNAs over the past twodecades (116 v. 68 percent) (522).

44The number of

graduates from nurse anesthetist training programsdropped by a precipitous 44 percent from 1980 to1988, due to a 48 percent reduction in the number of nurse anesthetist training programs (table 10-34)

(22). Reasons for program closure may include

p ganesthesiology residency programs and nurse anes-

thetist training programs (522). The eight States withrates below the national median for both providersall have large rural areas and below-average hospitalbed-to-population ratios (522).

Hospitals that lack the services of MD anesthesi-ologists may rely on CRNAs as the sole providers of anesthesia during surgical procedures. CRNAs ad-minister nearly 70 percent of all anesthetics given in

the United States (122).45

In 1982, 34 percent of

~~eSefi~eSre~eSenttien~erofme~rSh~e~efimASw~tionofNWe~eS~e~tSmd~~e~e~cmSWie~of~eS~=iolo@S~,

but they excludenurseanesthesia students andanesthesiologyresidents (522).

ds~~rdingto an~es~s~pmctim ~ e y conductedby the Center for Health Economics Research (J22), 19perC@OfaneStheSia Serviws

mtionwide are provided byCRNAsalone,48 percent by anesthesiologists and CRNAs together, and 33 pexcen t by anesthesiologists alone. when

anesthesiologists and CRNAs work together, i t i suswdly the CRNAwho actuaUy administers the anesthesia (60J).

46ficlud~fromthisa~ysis werehospi~in~eu.s. ~mtones,long.temc~emd F~~hO~i~,S~i~~hOSpi~S no tmeedng theHes l t h

Care FinancingAdministration’s defiitionofcommunityhospital, and hospitals notproviding surgical services.


Table 10-35--SuppIy of Certified Registered Nurse Anesthetists (CRNAs) and MD Anesthesiologists by State,1986, Ranked by CRNAs and MD Anesthesiologists Per 100,000 Residents

Anesthesia providers

CRNAs Anesthesiologists (CRNAs plus MD

anesthesiologists )

Per 100,000 Per 100,0o0 per 100,000

State Numbera

residents Rankc

Numberd

residents Ranke

residents

Alabama . . . . . . . . . . 562 Alaska . . . . . . . . . . . 34 Arizona . . . . . . . . . . 140 Arkansas . . . . . . . . . 243California . . . . .. 957Colorado . . . . . . . . . 181Connecticut . . . . . . 287Delaware . . . . . . . . . 78District of

Columbia. . . . . . . 61Florida . . . . . . . . . . 86oGeorgia . . . . . . . . . . 546Hawaii . . . . . . . . . . . 104

Idaho . . . . . . . . . . . . 99

Illinois . . . . . . . . . 810Indiana . . . . . . . . . . 119Iowa. . . . . . . . . . . . . 208Kansas . . . . . . . . . . . 326Kentucky . . . . . . . . . 301Louisiana . . . . . . . . 723

Maine . . . . . . . . . . . . 125 Maryland . . . . . . . . . 310 Massachusetts. . . . 456 Michigan . . . . . . . . . 992 Minnesota . . . . . . . . 774 Mississippi . . . . . . 2 6 3

Missouri . . . . . . . . . 611 Montana . . . . . . . . . . 59 Nebraska . . . . . . . . . 193 Nevada . . . . . . . . . . . 38 New Hampshire. . . . 84 New Jersey . . . . . . . 347 New Mexico . . . . . . . 117

New York. . . . . . . . . 800 North Carolina. . . 863

North Dakota . . . . . 129Ohio. . . . . . . . . . . . . 946Oklahoma 244

14.06.5

4.410.33.6

5.6

9.012.5

9.77.6

9.1

9.9

9.9

7.02.2

7.2

13.38.1

16.1

10.7

7.17.8

10.9

18.5

10.1

12.1

7.112.04.1

8.44.6

8.1

4.5

13.8

18.8

8.8

7 4

741.5

4716

5044

24

11

21

33

2319

19

3951369

29.5

4

15

37.5

3114

3

171237.5

13

49

27

4529.5

468

225

34

175

21263

1052,025

233

280

37

48822

36761

31

709374

160

126199

216

69

404582

502

267

87291

5183

81

53511

871,461

283

31765

164

4 . 4

4.08.3

4.5

7.77.2

8.8

5.9

7.77.2

6.1

5.8

3.1

6.16.8

5.55.1

5.34.8

5.9

9.2

10.05.5

6.4

3.35.8

6.2

5.2

8.7

5.36.8

6.0

8.2

4.5

4.5

7.1

5 0

46

48

7

44

10

12.55

30.5

1012.5

2732.5

50

271734.5

3936.5

4230.5

2.5

1

34.5

21

4932.5

2438

6

36.5

17

298

44

44

14

40

1 8 . 4

1 0 . 5

1 2 . 7

1 4 . 8

1 1 . 3

1 2 . 8

1 7 . 8

1 8 . 4

1 7 . 4

1 4 . 8

1 5 . 2

1 5 . 7

1 3 . 0

1 3 . 19 . 0

1 2 . 7

1 8 . 4

1 3 . 4

2 0 . 9

1 6 . 6

1 6 . 3

1 7 . 8

1 6 . 4

2 4 . 9

1 3 . 4

1 7 . 9

1 3 . 3

1 7 . 2

1 2 . 8

1 3 . 7

1 1 . 4

1 4 . 1

1 2 . 7

1 8 . 3

2 3 . 3

1 5 . 9

1 2 4



Oklahoma . . . . . . . . . 244Oregon . . . . . . . . . . . 168

Pennsylvania. .. ..1,772Rhode Island . . . . . 81

South Carolina. . . 333South Dakota . . . . . 141Tennessee . . . . . . . . 625Texas . . . . . . . . ....1,382Utah. . . . . . . . . . . . . 71 Vermont . . . . . . . . . . 41 Virginia . . . . . . . . . 525 Washington . . . . . . . 286

West Virginia. . . . 279 Wisconsin . . . . . . . . 350

Wyoming . . . . . . . . . . 34U.S. total . . . . . . . . . . . . . . . . . . .

7.46.3

14.98.49.9

19.9

13.18.4

4.37.7

9.2

6.5

14.47.3

6.78.4

3443

527

191

10

2748

3222

41.5

6

35

40

164208

82460

14019

309

1,065

15233

358

394

95

326

31

5.07.7

7.06.2

4.2

2.7

6.5

6.5

9.2

6.2

6.38.9

4.9

6.8

6.16.1

4010

152447

51

19.519.52.5

24

224

41

17

27

1 2 . 4

1 4 . 0

2 1 . 9

1 4 . 6

1 4 . 1

2 2 . 6

1 9 . 6

1 4 . 9

1 3 . 5

1 3 . 9

1 5 . 5

1 5 . 4

1 9 . 3

1 4 . 1

1 2 . 8

14.5

aActive me~ers in the America Association of Nurse Anesthetists, as of August 1986.

bBased on 1985 population.cRanked by CRNAS per capita.‘Active members in the American Society of Anesthesiologists, as of Dec. 31, 1986.%mked by MD anesthesiologists per capita.

SOURCE: Adapted from M.L. Rosenbach and J. Cromwell, “A Profile of Anesthesia Practice Patterns,” Health Affairs, vol. 7, No. 4, Fall 1988, pp. 118-131, exhibit 3.

Chapter 10--The Supply of Health Personnel in Rural Areas q259

Box 10-C—Provider Profiles: Nurses

Registered Nurses (RNs)

Although all RNs take the same licensure examination, basic nursing education is provided in a number of different settings (673). Programs vary in length and type of degree provided. Diploma programs, usually locatedin hospitals, are typically 3 years in length. Associate degree programs, typically located in community colleges,are generally 2 years long. Bachelor’s degree programs are located in colleges and universities and require a totalof 4 years of undergraduate education for degree completion. In recent years, there has been a trend away from the

diploma and toward the bachelor’s degree or associate degree as the route of entry into the RN work force. Associatedegree programs are still producing the majority of RNs (673). Many advanced nursing degree programs, such asthose preparing NPs, CNMs, and CRNAs, require a previous bachelor’s degree (673), and some States have initiatedplans to require a bachelor’s degree for RN professional practice (671). The total employed RN population includesRNs with advanced training (e.g., NPs, CNMs, CRNAs, clinical nurse specialists) who are either in clinical practiceor are employed in research, teaching, or administration (673).

Licensed Practical/Vocational Nurses (LP/VNs)

LP/VNs must complete a training program in practical nursing (typically 12 months long) before taking anational licensure examination (671). In California and Texas, the licensing laws refer to vocational nurses rather

than practical nurses (671). LP/VNs are not considered professional nurses because their skills and training are notequivalent to those of RNs (69). LP/VNs are responsible to RN supervisors under State nurse practice acts (69).

hospitals%

relied solely on CRNAs for anesthesia ily on registered nurses (RNs) employed in hospi-service provision (123);

4785 percent of these

hospitals were located in rural areas (123). Inisolated areas, a single CRNA may provide servicesin as many as four hospitals (699).

The high proportion of rural anesthesia servicesprovided by CRNAs suggests a concentration of these professionals in rural areas, but recent de-creases in the number of programs and graduatesmay disproportionately affect rural areas. A surveyof rural and urban hospitals in Texas found that thevacancy rate for CRNAs was 10 percent in ruralhospitals, compared with 2 percent in urban hospi-

tals. The impact of the national nursing shortage-inrural areas is difficult to determine due to thelimitations of these studies and their data sources,but available data suggest that rural areas are

suffering at least as much as urban areas. Smallerrural facilities are more sensitive to the loss of asingle nurse, because such a loss can critically affecttheir ability to deliver health services.

This section describes the national and ruralsupply of registered nurses (RNs) and licensedpractical/vocational nurses (LP/VNs) (see box 10-C).



p , p p ptals (595).

NURSES

The U.S. health care system employs over 3million nursing personnel at a wide range of professional levels and in a wide range of settings(671). Reports from nurse employers suggest arecent serious national shortage of nurses (698). Thenature and extent of this shortage have been the

subject of numerous studies at the national, State,and local levels. These studies have focused primar-

C).

National Supply 48

Current Supply

As of March 1988, there were just over 2 millionRNs licensed to practice in the United States,representing an increase of approximately 45 per-cent over the 1977 RN population (figure 10-5)(673). From 1984 to 1988, however, total RN

population increased by only 8 percent. The esti-mated total number of RNs employed in nursing in

47Seven~enPr~nt used anesthesiologists only, and 45 percent used both anesthesiologists and CRNAS. The remainder used otheI providers (e.g.,RNs, other physician specialists).

48A ~ b s ~ ~ n ~ e r of ~m= (~ ~rmnt of ~ s fi 1988) me emp loy~ p~-~e (673). B~ @ust~ for the perce)lklge of RN S e mp l o @

part-time in 1988 to produce estimates of full-time equivalent @l’’l3) RN and LP/VN supply. In 1988, when the total employed RN supply was 1.63mi l l i om the estimated FI’E supp ly was only 83 percent of th at, or 1.36 million (673). In 1983,FTE LP/VN supp ly was 87 percent of the estimated total

number of LP/VNs (671). The percentage of both R.Ns and LP/VNs who are emp loyed full-time varies somewhat by region and State (67J,673).


Figure 10-5-Employment Status of RegisteredNurses in the United States, Selected Years,

1977-1988

Million

2.0

1.5

1.0

.5

0

1977 1980 1984 1988

Year

~ Not in nursing m Ful l - t ime m P a r t - t i m e

SOURCE: Office of Technology Assessment, 1990. Data from U.S.Department of Health and Human Services, Health Resources

and Services Administration, Bureau of Health Professions,

Seventh Reporf to the Preskfent and Congress on the Status of Hea/th Personne/in the United States, DHHS Pub. No. HRS-P-OD-90-1 (Rockville, MD: HRSA, June 1990), table VIII-2.

1988 was approximately 1.6 million, or roughly 80percent of all licensed RNs (673). Both the propor-tion of licensed RNs who are practicing and the

proportion employed full-time have increased inrecent years (figure 10-5) (673). There were 668employed RNs per 100,000 residents in the UnitedStates as a whole in 1988-a 19 percent increaseover the 1980 ratio (table 10-36) (404,673). Thenumber of RNs employed in hospital settings hasincreased dramatically in recent years (table 10-37)(671,698).

I 1983 h f hi h d

residents as the West South Central region (table10-36) (673). Ratios in the States ranged from a lowof 442 in Louisiana to a high of 1,167 in Massachu-setts. Employed-RN-to-population ratios increasedin all States between 1980 and 1988, although therate of increase varied considerably, and a few Statesexperienced decreases during the latter part of thatperiod. Regions with the lowest ratios experienced

the highest rates of increase (table 10-36) (404,673).Regional variations are less pronounced for LP/

VNs (table 10-38). The national ratio of LP/VNs per100,000 residents was 231 in 1983. The only regionswith ratios well below this average were theMountain (173) and Pacific (176) regions (671).Interestingly, the two regions with the lowestrelative RN-to-population ratios in 1984 (East SouthCentral and West South Central) (table 10-36) had

high relative LP/VN-to-population ratios in 1983(278 and 274, respectively) (404)671).

Over two-thirds of RNs employed in nursing (in1988) and over one-half of employed LP/VNs (in1983) worked in hospitals (table 10-39) (671,681).Other major employment settings for RNs werenursing homes, ambulatory care settings, and publichealth settings. Other major employment settings for

LP/VNs were nursing homes and physicians’ ordentists’ offices. RN employment in ambulatorycare settings (e.g., group practice physician offices,HMOs, freestanding clinics) increased by 29 percentfrom 1984 to 1988, but it changed little in publichealth settings (673).

Future Supply

Th i f di f



In 1983, the most recent year for which data are

available, there were in the United States anestimated 781,506 LP/VNs, with 69 percent of theseactually employed in practical nursing. Approxi-mately 5 percent of all LP/VNs were also licensed topractice as RNs, and almost 12 percent of theLP/VNs who were not employed in practical nursingin 1983 were employed as RNs (678). The numberof LP/VNs employed in hospitals decreased sub-stantially between 1981 and 1988 (table 10-37)

(671,698).

Considerable State and regional variations inestimated RN supply exist (figure 10-6, table 10-36)(404,673). In 1988, for example, New England hadmore than twice as many employed RNs per 100,000

The main cause for concern regarding future

supply of nurses is the recent downward trend inenrollments in and graduations from nursing pro-grams. Total enrollments in basic RN nursingeducation programs decreased in all but three yearsbetween academic years 1975-76 and 1987, thenincreased slightly in 1988 (671,673). In 1989-90,first-time student enrollments in 4-year RN pro-grams increased by 6 percent over the previousyear-the first increase in 5 years (20). Enrollments

in practical nursing programs peaked in 1982-83,and they have since declined significantly (671).

The number of graduates from RN programs, afternearly a decade of increase, dropped significant.ly in1985-86 and has continued to decline (table 10-40)





Chapter 10--The Supply of Health Personnel in Rural Areas .263

Table 10-37-Registered Nurse (RN) and Licensed Practical/Vocational Nurse (LP/VP) Supply inU.S. Community Hospitals,a 1981-88

1981 1982 1983 1984 1985 1986 1987 1988

Total FTEs b

(1,000s) . . . . . . . 629 672 698 698 709 736 759 771FTEs per 100 patients

c

. . . . . 72.1 76.5 80.8 85.1 91.3 95.6 97.8 97.9 Vacancy rate. .. . . . . . . . . . . . . 7.6 5.3 4.4 4.6 6.3 11.0 11.3 NA

LP/VNs :

Total FTEs b

(l,OOOs). . . . . . . 234 238 230 205 187 174 170 171FTEs per 100 patients . . . . . 26.8 27.1 26.6 25.0 24.1 22.6 21.9 21.7

Vacancy rate. . . . . . . . . . . . . . . 5.5 3.4 2.8 3.3 NA NA NA NA

NOTE: NA = not available.aAs defined by the American Hospital Association.bFull_time equivalent.

cIncludes inpatient5 plUS outpatient visits converted to inpatient ewivalents.

SOURCE: Americm Hospital Association, Hospital Statistics, 1982-1990 eds. (Chicago, IL: AHA, 1982-1990);U.S. Department of Health and Human Services,Secretary’s Commission on Nursing, Secretary’s

Commission on Nursing:Final Re~ort, Volume I (Washington, DC: December 1988), figure 1; U.S.Department of Health and Human Services,Health Resources and Services Administration, Bureau ofHealth Professions, Sixth Report to the President and Congress on the Status of Health Personnel in

the United States, DHHS Pub. No. HRS-P-OD-88-1 (Rockville, MD: HRSA, June 1988), table 10-12.

Figure 10-6-Employed Registered Nurses (RNs) Per 100,000 Residents in the UnitedStates by State, March 1988



RNs per 100,000 residents:

c1 4 4 0 - 5 4 9 m 5 5 0 - 6 5 9 6 6 0 - 7 9 9 ~1800 a nd ov e r

SOURCE:Officeof Technology Assessment 1990. Based on data from U.S. Department of Health and HumanServices, Health Rssourcesand Services Administration, Bureau of Health Professions, Seventh ReporttothePresidentandCongress ~theStdusofHtih Pwsonndin the fJntiedStafes, DHHSPub. No.HRS-P-OD-90-l (Rockviile, MD: HRSA, June 1990), figureV111-8.

Table 10-38-Estimated Supply of Licensed Practical/Vocational Nurses (LP/VNs) by Region, 1983a

Rate per

100,000

Number residents

United States. . . . . . . . . . . . . .

New England . . . . . . . . . . . . .

Middle Atlantic . . . . . . . . .South Atlantic . . . . . . . . . .

East South Central . . . . . .

West South Central. . . . . .East North Central . . . . . .

West North Central . . . . . .

Mountain. . . . . . . . . . . . . . . .

Pacific . . . . . . . . . . . . . . . . .

539,463

33,004

82,88586,872

41,598

70,671

94,979

48,729

21,386

59,339

231

264

224224

278

274

229

280

173

176

aIncludes only nurses actually employed as Lp/VNS.

SOURCE: U.S. Department of Health and Human Ser-vices, Health Resources and Services Ad-

ministration, Bureau of Health Professions,Sixth Report to the President and ConEress

on the Status of Health Personnel in the

United States, DHHS Pub. No. HRS-P-OD-88-1(Rockville, MD: HRSA, June 1988), table 10-7.

(421}49SimilarlY, the number of graduates from

LP/VN programs increased until 1984-85 but has

since dramatically declined, dropping by almost

20,000 between 1984-85 and 1987-88 (table 10-40()).

While the number of programs preparing RNs has

increased slightly in recent years, the number of

LP/VN programs has decreased (table 10-40)(421)).

BHPr projects a continuing decline in graduates

from all basic nurSing education programs through

the year 2020 (673). Between 1990 and 2020,the

total supply of employed RNs is projected to

decrease by 2 6 percent(from 1 687 100 to l 642 900)

Table 10-39-Registered Nurses (RNs) Employed inNursing, 1988, and Employed Licensed Practical/

Vocational Nurses (LP/VNs), 1983, by PrimaryEmployment Setting

Employment setting Number Percent

Estimated RNs employediJl~S~, 1988

Hospital . . . . . . . . . . . . . . . . . . . 1,104,978Nursing home/extended

care facility. . . . . . . . . . . . . 107,805

Nursing education. . . . . . . . . . 30,005Community/public health. . . . 110,886

Student health service. . . . . 47,792

Occupational health . . . . . . . . 21,857

Ambulatory care. . . . . . . . . . . . 125,813Private duty nursing. . . . . . . 19,988

Self-employed. . . . . . . . . . . . . . 13,203

Other. . . . . . . . . . . . . . . . . . . . . , 43,321

Unknown. . . . . . . . . . . . . . . . . . . . 1,386

Total . . . . . . . . . . . . . . . . . . . 1,627,035

Estimated LP/VNs employedas LP/VNs, 1983

Hospital . . . . . . . . . . . . . . . . . . . . 310,842Nursing home. . . . . . . . . . . . . . . 121,398

Public/community health. . . . 13,574

Student health . . . . . . . . . . . . . 4,200

Occupational health . . . . . . . . 6,056

Physicians or dentists

office. . . . . . . . . . . . . . . . . . . . 48,969

Private duty. . . . . . . . . . . . . . . 19,959

Other . . . . . . . . . . . . . . . . . . . . . . 6,237Not known.. . . . . . . . . . . . . . . . . 8,229

Total . . . . . . . . . . . . . . . . . . . 539,465

67.9

6.6

1.8

6.8

2.91.3

7.7

1.2

0.8

2.7

0.1

100.0

57.6

22.5

2.5

0.8

1.1

9.1

3.7

1.21.5

100.0

apercentages may not add to 100 due to rounding.

SOURCES: U.S. Department of Health and Human Ser-

vices, Health Resources and Services Ad-

ministration, Bureau of Health Profess-ions, Division of Nursing, Rockville, MD,

unpublished data from the 1988 National

Sample Survey of Registered Nurses pro-

vided to OTA in 1989; U S Department of



decrease by 2.6 percent(from 1,687,100 to l,642,900),

while the supply of employed RNs relative to

population is projected to decrease by 17 percent

(from 674 to 558 per 100,000 residents) (673). The

total number of LP/VNs per 100,000 residents is

projected to peak in 2004 and to subsequently

experience a slow but steady decline (671).

The pool of potential nursing students also seems

to be shrinking. An ongoing study of career interests

of first-time freshmen college students conducted by

the University of CalifOrnia (Los Angeles) shows a

marked decrease in the numbers indicating an

interest in nursing (63).

vided to OTA in 1989; U.S. Department of

Health and Human Services, Health Resour-ces and Services Administration, Bureau of

Health Professions, Sixth Report to the

President and Congress on the Status of

Health Personnel in the United States, DHHS

Pub. No.HRS-P-OD-88-1 (Rockville, MD: HRSA,

June 1988), table 10-11.

The 1980s Nursing Shortage--Although in the

future there is likely to be a shortage of nurses dueto lack of nursing graduates, the shortage of RNs inthe 1980s was primarily due to an increase indemand (698). Demand factors included:

49’TheSefi~esinclude=dWteS ofall RNpro~S.Recent datafrom theAmericanAssociation ofCoUeges ofNursing(AACBO indicatetitt

nmroffwst-tiestident~tiwtesfiorn~y~p~~~ (exclu@smdmtSWhoWeNtidywSbutW~eup~a@toabac@a~~tede~e)

continuestodecreas+y 16percentbetween 1987and 1988,andby llpercentktween 1988snd l989(l9).EnrolhnentsinbaccalaureateRNprogra

alsocontinuetodecrease,althoughmore slowlyduringthepast2yearsWhencornparedwithprevioua years(20).


Table 10-40-Number of Programs PreparingRegistered Nurses (RNs) and Licensed Practical/

Vocational Nurses (LP/VNs) and Number of Graduates:1976-77 and 1981-82 through 1988-89

Number of Number of

Year programs graduates

RNs :1976 -77. . . . . . . . . . . . 1,358

1981 -82. . . . . . . . . . . . 1,4011982-83 . . . . . . . . . . . . 1,432

1983-84. . . . . . . . . . . . 1,466

1984-85. . . . . . . . . . . . 1,477

1985-86. . . . . . . . . . . . 1,473

1986-87. . . . . . . . . . . . 1,469

1987-88. . . . . . . . . . . . 1,465

1988-89. . . . . . . . . . . . 1,442

LP/VNs:

1976-77. . . . . . . . . . . . 1,318

1981-82. . . . . . . . . . . . 1,309

1982-83. . . . . . . . . . . . 1,295

1983-84. . . . . . . . . . . . 1,2971984-85. . . . . . . . . . . . 1,254

1985-86. . . . . . . . . . . . 1,165

1986-87. . . . . . . . . . . . 1,087

1987-88. . . . . . . . . . . . 1,068

1988-89. . . . . . . . . . . . 1,095

77,755

74,05277,408

80,312

82,075

77,027

70,561

64,839

NA

46,614

43,299

45,174

44,65436,955

29,599

27,285

26,912

NA

NOTE: NA= not available.

SOURCE: National League for Nursing, New York, NY,

unpublished data provided by staff at theU.S. Department of Health and Human Ser-vices, Health Resources and Services Admi-nistration, Bureau of Health Professions,Rockville, MD, 1990.

q increasing demand for RNs in hospitals due to

advances in medical technology, shorter hospi-tal stays, and increased severity of illness of hospital patients, which results in intensifica-tion of required RN services, and reduction inhospitals’ ancillary nursing staff, which in-creases the range of tasks that must be per-

full-time equivalent (FTE)RNs per l00 patients incommunity hospitals increased by 21 percent from1983 to 1987 (from 80.0 to 97.8) (figure 10-7),RNvacancy rates in these hospitals increased from 4.4percent to 11.3 percent during the same period (table10-37) (698).

50As the number of RNs in hospitals

has increased, both the number of LP/VNs andreportedly/VNvacancyrates have decreased (fig-

ure 10-7, table 10-37) (671,698). Nursing homes,which employed almost 7 percent of RNs in 1988(673), reported an RN vacancy rate of 8 percent in1987 (462). The number of RNs employed innursing homes may increase in the near future due tonew requirements for greater RN staffing in Medicare-and Medicaid-certified nursing homes (Public Law100-203)(462,673).

Rural SupplyThe proportion of RNs who work in rural areas

has decreased in recent years, but it is not clearwhether this is the result of decreased demand inrural settings or decreased supply of nurses willingto locate there. In 1988, 17 percent of all RNsemployed in nursing in the United States wereemployed in rura1 areas, compared with 20 percentin 1980 (table 10-41)(681). The rural/urban distribu-

tion of RNs varies considerably by region. The WestNorth Central and East South Central regions hadthe highest proportions of their nurses in rural areasin 1988 (31 percent and 30 percent, respectively)(681 ). The distribution of RNs across rural and urbanareas in 1988 cannot be fully explained by thedistribution of U.S. registered hospital beds, 21percent of which were located in rural areas in 1988(178).

51



creases the range of tasks that must be per-formed by RNs;

. increasing demand for RNs in nonhospitalsettings (e.g., ambulatory care and home healthcare); and

q increasing opportunities for RN employmentoutside of traditional medical settings (628).

Increase in demand for RNs in the hospital sector

is evidenced by increases in both RN employmentand vacancy rates. Although the average number of

Rural RNs are concentrated in the most populatedcounties. According to a recent analysis of 1988data, only 8.7 percent of all RNs employed innursing were located in counties of fewer than50,000 residents (table 10-42) (317). Most of thesewere in counties of more than 25,000 residents (table10-42) (317).

52

Compared with RNs in larger counties, RNs in

small counties (50,000 or fewer residents) axe older,more likely to work full-time, more likely to work in

Wvidence of the nursing shortage is typically expressed in terms of budgeted staff vacancy rates at institutions which employ nurses. Budgetedvacancy rates may not be a l r u e reflection of unfilled positions, however, due to use of temporsry nursing staff, and due to the tendency of a d rmm“ “Srrators

to use budgeted vacancies as a tool to retain discretionary funds for staff development (462).

SIDCZ- O-pancy rates in rural hospitals in recent years (see ch . 5) may help to explain th e shift of RN s from~ to wb~ m.

5% M @ys is, some of th e larger counties (more than 50,000 residents) we nonmetro counties.

a


Figure 10-7—Registered Nurses (RNs) and Licensed Practical/Vocational Nurses (LP/VNs) in U.S. CommunityHospitals:

aTotal FTEs

band FTEs per 100 Patients,’ 1981-88

1981 1082 1983 1984 1985 1988 1987 1988

Total FTEs

m RNs ~ LP/VNs

a~ defined by the Anerioari Hospital Association.

bFull-time equivalent.

120 I

I

1981 1982 1983 1984 1986 1986 1987 1988

FTEs per 100 patients

n RNs = LP/VNs

c[n~~es inpatients plus outpatient visits converted to inpatient equivalents.SOURCE: Office of Technology Assessment, 1990. Data from American Hospital Assodation, M.spk/StdMks (Chicago, IL: AHA, 1982-1989 eds).

Table 10-41—Metropolitan/Nonmetropolitan Distribution of Registered Nurses (RNs) Employed in Nursingin the United States by Region, 1980 and 1988a

Employed RNs, 1980 Employed RNs, 1988Total

b Metro Nonmetro Total

b Metro Nonmetro

United States. . ....1,268,870

New England. . . . . . . . . 106,027 Middle Atlantic. . . . . 252,435East North Central. . 231,324

West North Central. . 111,206South Atlantic. . . . . . 186,355East South Central. .62,382

West South Central. .87,375 Mountain. . . . . . . . . . . .61,154Pacific. . . . . . . . . . . . . 170,612

1,010,934 (80%)

80,297 (76%)220,639 (87%)186,148 (80%)71,463 (64%)141,746 (76%)44,854 (72%)71,199 (81%)42,744 (70%)151,844 (89%)

257,936 (20%)

25,730 (24%)31,796 (13%)45,176 (20%)39,743 (36%)44,609 (24%)17,528 (28%)16,176 (19%)18,410 (30%)18,768 (11%)

1,626,026

130,838293,961294,850135,382259,50282,594125,30781,828221,765

1,344,143(83%) 281,883(17%)

106,908 (82%)262,474 (89%)248,730 (84%)93,432 (69%)207,568 (80%)58,182 (70%)104,866 (84%)61,403 (75%)200,581 (90%)

23,930 (18%)31,487 (11%)46,120 (16%)41,950 (31%)51,934 (20%)24,412 (30%)20,441 (16%)20,425 (25%)21,184 (10%)

a1980 data as of Novefier; 1988 data as of March.



bTotal excludes RN s whose metro or nonmetro location was not known.SOURCE: U.S. Department of Health and Human Services,Health Resources and Services Administration, Bureau of

Health Professions,Division of Nursing, Rockville, MD, unpublished data from the 1980 and 1988 National Sample Surveys of Registered Nurses.

nursing home or public health settings, less likely towork in hospitals, and less likely to have a baccalau-reate degree (table 10-43) (317). RNs in small

counties are also more likely to work in administra-tive or supervisory positions. Most of these charac-teristics are most pronounced in the smallest coun-ties; for example, RNs in the smallest counties aremore than three times as likely as RNs in the largestcounties to work in a nursing home or extended carefacility. Oddly enough, within the smaller counties,the percentage of RNs with a baccalaureate degree

as their highest degree in nursing is highest in thesmallest counties (table 10-43) (317). This findingmay be indicative of a more pressing need for

well-trained RNs in the smallest, most remotefacilities.

Rural RNs are less likely than urban RNs to beemployed in nursing (77 v. 81 percent in 1988)(681). Analysis of 1984 national survey data re-vealed that 14 percent of RNs who resided in ruralareas commuted to urban areas to work, while only

*


Table 10-42—Estimated Number and Distribution ofRegistered Nurses Employed in Nursing by County

Population Size, 1988

county Estimated Percent population size

anumber of RNs distribution

b

All U.S. counties. . ......1,627,035 100.0

More than 50,000.......1,485,999 91.350,000 or fewer . . . . . . . . 140,057 8.7

25,001 to 50,000: . . . 79,117 4.810,001 to 25,000. . . . 46,955 2.910,000 or fewer.. . . . 13,986 0.9

acounty population size does not necessarily reflect

metro or nonmetro status.bPercentages may not add to 100 due to rounding.

SOURCE: D.A. Kindig,University of Wisconsin, Madison, WI, and H. Movassaghi, IthacaCollege, Ithaca,NY, unpublished analysisof data from the 1988 National Sample

Survey of Registered Nurses (provided bythe Division of Nursing, Bureau of HealthProfessions) conducted under contract withthe University of North Dakota Rural HealthResearch Center, Grand Forks, ND, 1989.

2 percent of RNs residing in urban areas commutedto rural practice sites (699).

Data from selected States indicate substantial

rural/urban differences in RN and LP/VN distribu-tion. For example:

q

q

In Texas, in 1986, the number of employed RNsper 100,000 residents was 228 in rural counties,compared with 460 in urban counties (708).

In Arizona, in 1987, the total number of RNsper 100,000 residents was also much lower inrural than in urban counties (477 v. 850).

LP/VNs, and critical care RNs in this State were onlyslightly higher in rural than in urban hospitals (595).

Nurse Supply In Rural and Urban Hospitals

Rural hospitals have markedly fewer RNs anddistinctly lower RN-to-LP/VN ratios than theirurban counterparts (table 10-44) (625). Among rural

hospitals, hospitals in frontier areas have especiallyfew FTE RNs--as little as one-fifth as many FTERNs as nonfrontier rural hospitals of comparablesize. Medicare-certified sole community hospitalstend to have slightly larger FTE RN staffs than thoseof other rural hospitals (625).

In contrast, rural hospitals of any given sizegenerally have slightly more FTE LP/VNs than theirurban counterparts (table 10-44). Again, however,

frontier hospitals have the fewest FTE LP/VNs(625).

Urban hospitals have up to two times as manyFTE RNs per FTE LP/VN as do rural hospitals of comparable size (table 10-44) (625), reflecting agreater reliance on nurses with less training andlower salaries in rural hospitals. It is unclear whetherthe greater representation of LP/VNs in rural hospi-tals is due to the hospitals’ inability to pay the higherRN salaries, their inability to recruit qualified RNsfrom the larger national pool, or a lower demand forRNs in these hospitals.

Eighteen percent of large urban hospitals and 9.5percent of rural hospitals reported closing beds in1987 due to shortage of nursing staff (699). Al-though a larger proportion of rural than urbanhospitals report no vacant RN positions, high RN



q

LP/VN availability was also lower in rural thanin urban counties (186 v. 238 per 100,000)(220).

In Oklahoma, in 1987, the total number of RNsper 100,000 residents was again much lower inrural than in urban counties (397v. 686), but theratio of LP/VNs to 100,000 residents wasactually higher in rural than in urban counties(387 v. 286) (451).

These differences may be explained to some extentby rural/urban distribution of hospitals, where mostRNs and LP/VNs are employed. In Texas, in 1986,for example, only 19 percent of the State’s hospitalbeds were located in rural counties, and 42 of the 43Texas counties without a hospital were rural (708).A recent study found that vacancy rates for RNs,

vacancy rates (over 15 percent) are more common inrural than in urban hospitals (699). Because mostrural hospitals are small and employ relatively fewRNs, they may be subject to extreme shifts invacancy rates, and they may be more sensitive to theloss of a single nursing employee.

Data are scarce regarding the extent of the nursingshortage in ambulatory and other nonhospital, non-nursing home health care settings, which employ

approximately 25 percent of all RNs and 22 percentof all LP/VNs (table 10-39) (671,681). Lack of suchdata hinders accurate assessment of the extent of thenursing shortage. This limitation is particularlytroubling given the recent increase in RN employ-ment in ambulatory care settings (673) and given therelatively large proportion of RNs in small rural


Table 10-43-Characteristics of Registered Nurses (RNs) Employed in Nursing by County Population Size,a 1988

Countypopulation size more than 50,000 25,001 to 10,001 to 10,000

All Us. 50,000 or fewer 50,000 25,000 or fewercount i es residents residents residents residents residents

Percent of RNs:

Basic nursing education:Diploma. . . . . . . . . . . . . . . . . . . . . ...44.6

Associate degree. . .............31.5Baccalaureate, mastersor doctoral degree. . . . . . . . . . . . 23.5

Unknown . . . . . . . . . . . . . . . . . . . . . . . . 0.4Total

b

. . . . . . . . . . . . . . . . . . . . . . 100.0

Highest nursing degree:Diploma. . . . . . . . . . . . . . . . . . . . . ...36.5

Associate degree. . .............28.0Baccaluareate degree. . .........28.7 Masters or doctoral degree . . . . . 6.3Unknown . . . . . . . . . . . . . . . . . . . . . . . . 0.4

Total

b

. . . . . . . . . . . . . . . . . . . . . . 100.0Received degree/certificate from nurse practitioner/midwife program:

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 No. . . . . . . . . . . . . . . . . . ...........96.1Unknown . . . . . . . . . . . . . . . . . . . . . . . . 0.5

Total b. . . . . . . . . . . . . . . . . . . . . . 100.0

Age:<25. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.725-34 ..........................33.335-44 . . . . . . . . . . . . . . . . ..........31.745-5.4 . . . . . . . . . . . . . . . . . . . . . . . . . . 19.2>55. . , . . , . . . . . . . . . . . . . . . . . . . . . . 10.7Unknown . . . . . . . . . . . . . . . . . . . . . . . . 0.5

Total b

. . . . . . . . . . . . . . . . . . . . . . 100.0

Employment status:Full-time. . . . . . . . . . . . . . . . . . . . . .67.6Part-time. . . . . . . . . . . . . . . . . . . . . . 32.4Full-time/part-time . . . . . . . . . . . . 0.1

Total . . . . . . . . . . . . . . . . . . . . . . 100.0

Field of employment:Hospital . . . . . . .................67.9 Nursing home/extended care. . . . . 6.6

44.530.9

24.20.4

100.0

36.127.229.56.70.4

100.0

3.596.00.5

100.0

4.833.631.619.010.40.5

100.0

67.432.50.1

100.0

68.96.0

45.638.6

15.50.2

100.0

41.136.220.12.50.2

100.0

2.397.40.2

100.0

3.430.431.221.413.60.2

100.0

69.530.5*

100.0

57.813.5

43.840.5

15.40.3

100.0

39.538.518.82.90.3

100.0

2.896.90.3

100.0

3.730.431.820.413.50.2

100.0

71.128.9*

100.0

60.411.8

47.1

37.2

15.50.2

100.0

42.734.221.11.80.2

100.0

1.698.20.2

100.0

2.731.131.621.213.20.2

100.0

67.132,9*

100.0

54.714.5

50.9

32.4

16.7*

100.0

44.529.124.32.1*

100.0

1.998.1*

100.0

4.027.725.827.514.70.2

100.0

68.032.0*

100.0

53.719.8



Nursing education . . . . . . . . . . . . . . 1.8Public/community health . . . . . . . . 6.8

Ambulatory care, . . . . . . . . . . . . . . . 7.7Other

C. . . . . . . . . . . . . . . . . . . . . . . . . 8.9

Unknown . . . . . . . . . . . . . . . . . . . . . . . . 0.1Total

b

. . . . . . . . . . . . . . . . . . . . . . 100.0

1.86.37.79.20.1

100.0

1.811.87.77.30.0

100.0

2.410.57.87.1*

100.0

0.913.48.28.20.1

100.0

1.214.45.75.4*

100.0

counties who work in these settings (table 10-43)(317).

OTHER HEALTH PROFESSIONALS

Dentists

National Supply

In 1986, there were 143,000 practicing dentists inthe United States--a 40 percent increase in absolutenumbers since 1970, and a 20 percent increase in the

active dentist-to-population ratio (table 10-45)(671).Of these dentists, 85 percent were in generalpractice, but this proportion is declining (671). From

1981 to 1987, the general and pediatric dentist-to-population ratio increased by only l.4 percent, whilethe dental specialist-to-population ratio increased by35 percent (table 10-46) (686). The trend towardsspecialty practice in dentistry is slight comparedwith that seen in medicine, but it maybe cause forconcern in the future if overall supply decreases(table 10-47) (673).


Table 10-43--Characteristics of Registered Nurses (RNs) Employed in Nursing by County Population Size,a

1988-Continued

Countypopulation size more than 50,000 25,001 to 10,001 to 10,000

All U.S. 50,000 or fewer 50,000 25,000 or fewercounties residents residents residents residents residents

Percent of RNs:

Title of position: Administrator/Assistant

administrator. . . . . . . . . . . . . . . . . 6.0 5.6 10.5 8.4 11.4 19.6Supervisor . . . . . . . . . . . . . . . . . . . . . 5.6 5.2 9.9 10.1 10.0 8.3Instructor . . . . . . . . . . . . . . . . . . . . . 3.8 3.8 4.0 4.7 3.3 2.6Staff/general duty nurse . . . . . . . 66.9 67.3 62.5 62.6 63.2 59.6Practitioner/midwife . . . . . . . . . . . 1.4 1.4 1.4 1.7 1.1 1.2Clinical specialist . . . . . . . . . . . . 1.8 1.9 0.7 0.7 0.7 0.4Certified nurse anesthetist. . . . 1.0 1.0 1.4 1.3 1.5 1.5Other . . . . . . . . . . . . . . . . . . . . . . . . .13.0 13.2 9.3 10.2 8.7 6.9Unknown . . . . . . . . . . . . . . . . . . . . . . . . 0.4 0.4 0.2 0.3 0.1 *

Total . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0

NOTE: * = less than 0.05 percent of total.acounty population size does not necessarily reflect metro Or ‘“~etro ‘

tatUs.

bpercentages may not add to 100 due to rOundin6.

C“Other” includes the following: student health, occupational health, private duty,other.

dwotheru includes the following: consultant, head nurse/assistant head nurse, nurse private duty, and other.

SOURCE: D.A. Kindig, University of Wisconsin, Madison, WI, and H. Movassaghi, Ithaca

self-employment, and

clinician, research,

College, Ithaca, NY,unpublished analysis of data from the 1988 National Sample Survey of Registered Nurses (provided bythe Division of Nursing, Bureau of Health Professions) conducted under contract with the Universityof North Dakota Rural Health Research Center, Grand Forks, ND, 1989.

Box 10-D—Provider Profile: Dentists

Dentists undergo 4 years of post-baccalaureateundergraduate training in general and some spe-cialty dentistry (671). Graduates of these programsmay enter dental residency programs to receivetraining in orthodontics, oral and maxillofacial

i d i d d i d d i

creased national supply has had little effect on Stateand regional distribution.

In 1988, there were 793 designated dental HMSAsin the United States, with a resident population of almost 16 million. An estimated 1,729 dentistswould be needed to remove these designations. Over70 percent of all dental HMSAs are in rural areas.

53



surgery, periodontics, pedodontics, endodontics,prosthodontics, public health dentistry, or oralpathology (671).

Variations inactive dentist supply amonggeo-. . —

graphic regions and States areas great as for otherhealth professions. In 1986, the ratio of dentists to100,000 residents in the United States was 57.3.

Ratios in the States ranged from a high of 76.2 inConnecticut to a low of 35.2 in Mississippi (671).Regionally, ratios in the Northeast were well abovethe national average, while the South fell well below(671). These patterns show little difference fromthose existing in 1970 (671), suggesting that in-

Trends in the number of dental students suggest aleveling off in future supply. For example:

q

q

q

the number of applicants to dental schoolsdecreased by nearly two-thirds between 1975and 1986, from 15,734 to 5,724;the number of first-year enrollments decreasedby 27 percent from 1978-79 to 1986-87; andthe number of graduates decreased by 14percent from 1982-83 to 1985-86(671). -

Rural Supply

The distribution of dentists across urban and ruralareas is very similar to that of physicians. For all

nswch.ll,tible 11-5.


Table 10-44-Estimated Supply of Registered Nurses (RNs) and Licensed Practical Vocational Nurses (LP/VNs)in U.S. Registered Community Hospitals by Metropolitan/Nonmetropolitan, Frontier, and Sole Community

Hospital Status, 1987

Mean number of estimated FTEaRNs, by hospital bed size:

6-24 25-49 50-99 100-199 200-299

All U.S. community hospitals b. . . . . . . . . . . . . 7.6 15.4 37.3 90.5 186.8

Metro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.5 22.6 48.8 105.2 197.6

Nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3 14.2 31.8 69.9 138.9 Within nonmetro:

Frontier . . . . . . . . . . . . . . . . . . . . . . . . . . 6.7 9.8 16.3 32.5* 26.0* Not frontier . . . . . . . . . . . . . . . . . . . . . . 7.5 15.0 33.4 70.8 139.8

Sole community hospitald. . . . . . . . . . 8.1 15.4 36.2 81.7 132.9*

Not sole community hospital . . . . . . . 7.1 14.0 31.3 68.7 139.6--------------------------------------------------------------------------------------------------------------

Mean number of estimated FTEaLP/VNs, by hospital bed size:

6-24 25-49 50-99 100-199 200-299

All U.S. community hospitals b. . . . . . . . . . . . . 3.5 7.4 15.2 27.8 45.3

Metro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6 7.5 15.7 27.0 43.0 Nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6 7.4 14.9 28.9 55.5

Within nonmetro:Frontier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.o 4.3 6.9 6.9* 18.0* Not frontier . . . . . . . . . . . . . . . . . . . . . . . . . 3.9 8.0 15.7 29.5 55.8

Sole community hospitald. . . . . . . . . . . . . 2.7 6.4 13.3 29.5 45.5*

Not sole community hospital . . . . . . . . . . 3.9 7,6 15.1 28.9 56.5--------------------------------------------------------------------------------------------------------------

Estimated FTEaRN-to-LP/VN ratio

c, by hospital bed size category:

6-24 25-49 50-99 100-199 200-299

All U.S. community hospitals b d

. . . . . . . . . . . 2.88 3.11 3.81 5.70 8.74 Metro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.82* 4.25 4.57 6.69 9.75 Nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.75 2.91 3.45 4.33 4.28

*,*,, NOTE: indicates that the figure is based on fewer than 30 cases.aFull-time e~ivalent.

bThe definition ‘f

“community hospital” used by OTA in this analysis differs slightly from that used by the American Hospital Association (see app. C)cRatios were calculated

using nonrounded fi8ures-

d130

hospitals without any LP/WS, were dropped from the analYsis.

SOURCE: U.S. Congress, Office of Technology Assessment, analysis of data from American Hospital Association

1987 Survey of Hospitals performed for Rural Health Care report (see C)



1987 Survey of Hospitals, performed for Rural Health Care report (see app. C).

dentists, office-based dentists, and general practiceand pediatric dentists, ratios per 100,000 residentswere much lower in rural than in urban counties in1987 (table 10-48) (686). Within rural counties,ratios were directly related to county size, with the

smallest counties (fewer than 2,500 residents) hav-ing fewer than one-half as many dentists per capitaas the largest counties. Interestingly, the greatestincreases in both general and specialist dentistsupply between 1981 and 1987 occurred in thesmaller rural counties (table 10-46)(686). However,in 1987, 183 counties in the United States still hadno general practice or pediatric dentist (table 10-48)

(686). All but two of these counties were rural

counties of fewer than 25,000 residents, and most of these were counties of low population density.

Data on the age distribution of dentists show nonotable rural/urban differences, but the proportion of dentists who are young decreased substantially in allareas between 1981 and 1987 (686). This trendreflects the decreasing number of new graduates in

recent years. As older dentists retire, rural areas willhave to compete with urban areas for an increasinglylimited supply of new dentists.


Table 10-45-Supply and Distribution of Active Dentists by General and Specialty Practice, 1970,1980, and 1986a b

1970 1980 1986

Dentists Dentists Dentists

per per per100,000 100,000 100,000

Specialty Number Percentc people

b Number Percent

c people

b Number Percent

c people

b

All active. .. .. ... ... lO2,2OO 100.0 49.5 126,200 100.0 55.2 143,000 100.0 58.9

General practice . . . . . .92,88090.9 45.0 109,050 86.4 47.7 121,700 85.1 50.2 All specialties . . . . . . . 9,320 9.1 4.5 17,150 13.6 7.5 21,300 14.9 8.8

Orthodontics. ... ... .3,9ooOral & maxillo-

facial surgery. . . 2,190Periodontics . . . . . . . . . 930Pedodontics. . . . . . . . 1,070Endodontics. . . . . . . . . . 460Prosthodontics. . . . . . . 590Public health

dentistry . . . . . . . . . . . 90

Oral pathology . . . . . . . . 90

3.8

2.10.91.00.50.6

0.1

0.1

1.9

1.10.50.50.20.3

*

*

6,560 5.2

3,960 3.12,240 1.82,060 1.61,170 0.9950 0.8

110 0.1

100 0.1

2.9

1.71.00.90.50.4

0.1

*

7,150 5.0 2.9

4,730 3.3 1.93,030 2.1 1.22,600 1.8 1.11,900 1.3 0.81,560 1.1 0.6

170 0.1 0.1

160 0.1 0.1

NOTE: “*” = fewer than 0.05 dentists per 100,000 people.aIncludes dentists in Federal service.bAll ratios are based on total population.

cPercentages may not add to 100 due to rounding.

SOURCE: U.S. Department of Health & Human Services, Health Resources and Services Administration, Bureau ofHealth Professions, Sixth Report to The President & Congress on The Status of Health Personnel in TheUnited States, DHHS Pub. No. HRS-P-OD-88-1 (Rockville, MD: HRSA, June 1988), table 5-4.

Table 1046-Number of General Practice and Pediatric Dentists and Other Specialty Dentists Per 1OO,OOOResidents by Type of County, 1981 and 1987

General practice and pediatric dentists

a

Other specialties

Rate per Rate per100,000 residents Percent 100.000 residents Percent

change, change,1981 1987 1981-87 1981 1987 1981-87

Metro 45 7 46 2 1 2 7 0 9 3 32 6



Metro . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.7 46.2 1.2 7.0 9.3 32.6 Nonmetro. . . . . . . . . . . . . . . . . . . . . . . . . 31.2 31.6 1.2 2.0 3.0 49.9

50,000 or more. . . . . . . . . . . . . . . . 34.2 34.0 -0.7 3.8 5.5 43.525,000 to 49,999. . . . . . . . . . . . . . 31.8 32.2 1.2 1.7 2.7 52.610,000 to 24,999. . . . . . . . . . . . . . 28.2 29.1 3.0 0.5 0.8 67.65,000 to 9,999. . . . . . . . . . . . . . . . 25.8 27.1 5.1 0.2 0.4 103.52,500 to 4,999. . . . . . . . . . . . . . . . 25.5 25.5 0.1 0.1 0.7 420.5fewer than 2,500. . . . . . . . . . . . . . 13.2 14.4 8.7 0.0 0.0 0.0

Population < 10,000:<=6 persons/square mile. . . . 27.7 28.7 3.7 0.1 0.5 520.6>6 persons/square mile. . . . 23.9 25.0 4.7 0.2 0.4 86.3

U.S. total . . . . . . . . . . . . . . . . . . . . . . . . 42.3 42.9 1 .4 5 . 8 7 . 9 34.7

aIncludes both full-time and part-time dentists. Part-time dentists are counted as full-time dentists.

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau ofHealth Professions, Office of Data Analysis and Management, Rockville, MD, unpublished data from the



Table 10-47-Supply of Active Dentists in the UnitedStates: Estimated 1988 and Projected 1990-2020 Box 10-E—Provider Profile: Pharmacists

In order to obtain a license, pharmacists mustcomplete either a 5-year baccalaureate educationprogram or a 6-year doctoral program (671). Theamount of preprofessional college study requiredby these programs varies from O to 2 years. Thenumber of entry-level doctoral pharmacy programsand degrees awarded has increased in recent years,

and this increase is projected to continue. The majordimensions of pharmacy practice include: generalmanagement and administration of the pharmacy ;activities related to processing the prescription;drug-related decisionmaking and patient care func-tions; drug preparation, distribution, and control;and education of health care professionals andpatients (671).

Number of Active dentistsactive per 100,000

Year dentists peoplea

1988 . . . . . . . . . . . . . . . 146,800 59.41990 . . . . . . . . . . . . . . . . .149,700 59.82000 . . . . . . . . . . . . . . . . .154,600 57.62010 . . . . . . . . . . . . . . . . .151,200

53.52020 . . . . . . . . . . . . . . . . .140,700 47.8

aRatios are based on total population, including Armed Forces overseas ,as of July 1 for 1990 andsucceeding years.

SOURCE : U.S. Department of Health and Human Ser-vices, Health Resources and Services Admin-

is trat i on, Bureau of Health Professions,Seventh Report to the President and Cong-ress on the Status of Health Personnel in

the United States, DHHS Pub. No. HRS-P-OD-

90-I (Rockville, MD: HRSA, June 1990),table VII-A-5.

Table 10-48--Number of Dentists Per 100,000 Residents and Number of CountiesWithout General Practice orPediatric Dentists by Typeof County, 1987

Counties without general practice Number of dentists

a per 100,000 residents or pediatric dentists, 1987

General practice Number of ResidentTotal Office-based and pediatric counties population

Metro. . . . . . . . . . . . . . . . . . . . . . . 57.7 55.5 46.2

31.6

34.032.229.127.125.514.4

2

181

00

11414881

15,400

731,500

00

141,200291,700178,300120,300

Nonmetro. . . . . . . . . . . . . . . . . . . . 35.3 34.6

50,000 or more. . . . . . . . . . .25,000 to 49,999. . . . . . . . .10,000 to 24,999. . . . . . . . .5,000 to 9,999. . . . . . . . . . .2,500 to 4,999. . . . . . . . . . .fewer than 2,500. . . . . . . . .

40.435.530.428.126.615.0

39.534.829.827.526.314.4

Population < 10,000:<=6 persons/square mile. .>6 persons/square mile 29.726 0 29.225 4 28.725 0 11557 272,600333 100



>6 persons/square mile.. 29.726.0

52.7

29.225.4

50.8

28.725.0

42.9

11557

183

272,600333,100

746,900U.S. total . . . . . . . . . . . . . . . . . .

aIncludes both full-time and part-time dentists.

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau ofHealth Professions, Office of Data Analysis and Management, Rockville, MD, unpublished data from the


Pharmacists percent from 1970 to 1988 (table 10-49) (673).

Significant trends in the pharmacy profession in-NationalSupply elude:

an increase in the proportion of pharmacistswho are female (from 4 percent of the activeworkforce in 1950 to 26 percent in 1988)(673);

an increase in the percentage of minoritypharmacists (from 8.9 percent in 1980 to 10.5

There were an estimated 157,800 practicing q

pharmacists in the United States in 1988 (673).Paralleling the pattern in dentist supply, the absolutenumber of pharmacists increased by 40 percent and q

the pharmacist-to-population ratio increased by 17


Table 10-49-Supply of Professionally ActivePharmacists, Selected Years: Estimated 1970-1988,

and Projected 1990-202@

Number of active Active pharmacistsYear pharmacists per 100,000 people

b

1970. . . . . . . . . . . . . 112,600 54.51980. . . . . . . . . . . . . 142,400 62.2

1988. . . . . . . . . . . . . 157,800 63.81990. . . . . . . . . . . . . 161,600 64.52000. . . . . . . . . . . . . 181,400 67.62010. . . . . . . . . . . . . 200,500 71.02020. . . . . . . . . . . . . 213,800 72.6-----------------------------------------------------

Percent change,1970-1988. . . . . . . . . . 40.1 17.1

Percent change,1988-2020. . . . . . . . . . 35.5 13.8

alnclUde~ pharmacists in Federal service.~atios based on total population, including ArmedForces overseas, as of July 1.

SOURCE: U.S. Department of Health and Human Ser-vices, Health Resources and Services Admin-istration, Bureau of Health Professions,Seventh Report to The President & Congresson The Status of Health Personnel in TheUnited States, DHHS Pub. No. HRS-P-OD-90-1

(Rockville, MD: HRSA, June 1990), tableXII-1.

q

percent in 1988)(67.?); anda change in professional focus from merelydistributing drugs to providing a wider range of services, including quality assurance, patienteducation, patient care activities, and monitor-ing in order to reduce adverse drug effects(671).

After decreasing for a number of years, enroll-

Figure10-8--First Year Enrollment in U.S. Schoolsof Pharmacy, Academic Years 1969-70 Through

10,000

8,000

6,000

4,000

2,000

1;6..

1985-86”—

—

—-70 1974-75 1979-80 1984-85

—

/

—

Academic year

alnciudes students in the first of 3 years of professional phmmcy

ecfucation. Excludes students in pre-pharmacyeducation.

SOURCE:Office of Technology Assessment 1990. Data from U.S.Department ofHealthandHuman Services, Health Resourcesand Services Administration, Bureau of Health Professions,Sixth Report to ThePresident andC%ngress on7he StatusofHea/th Personne/ in The United States, DHHS Pub. No.HRS-P~D-88-l (Rockville,MD: HRSA, June 1988}table8+.

ernment agencies, and other areas (671). The FederalGovernment at one time designated pharmacy HMSAs

but no longer does so (see ch. 11).

BHPr projects continuing increases in both thenumber of active pharmacists and the pharmacist-to-population ratio over the next three decades (table10-49) (673). The increasing number of femalepharmacists in the work force may lower the overallnumber of FTE pharmacists, since female pharma-cists tend to work fewer hours than their male

counterparts (673). Despite recent increases inl h d d i t i l d



After decreasing for a number of years, enrollments in U.S. schools of pharmacy have recentlyincreased slightly, although they are still well belowthe peak level reached in 1974-75 (figure 10-8)(671). As of 1988, there were 74 colleges of pharmacy in the United States (466).

The National Association of Boards of Pharmacyreported that 68 percent of all active pharmacists in

1986 were in community pharmacies, with the greatmajority in chain store pharmacies (671). Only 8percent were in independent establishments. Justover 20 percent were working in hospital settings,and the remaining 12 percent were employed inmanufacturing, wholesale practice, teaching, gov-

counterparts (673). Despite recent increases insupply, however, demand is outpacing supply, andmany employers have reported difficulty in recruit-ing for vacant pharmacist positions (673). Takinginto account recent trends in the output of thepharmaceutical industry, as well as the expandedclinical role played by pharmacists, future require-ments may continue to exceed supply.

Rural Supply

Current information on the national rural/urbandistribution of pharmacists is scarce. No nationalcensus of pharmacists has been conducted since the1970s, and no information on the rural/urban distri-bution of pharmacists is available from that census


(466).54 State studies that examined the rural/urbandistribution of pharmacists during the 1980s suggestthere are a few areas with shortages but little overallreason for concern.

q

q

q

q

q

In Georgia, in 1983, only one county lacked alicensed pharmacist, and the pharmacist-to-100,000 population ratio was only slightlylower in rural than in urban counties (81 v. 88)

(740). In Texas, in 1988, 14 rural counties had nopharmacist (575).

In Arizona, in 1987, the average pharrnacist-to-100,000 population ratio in the 13 rural coun-ties was 47 (range 18-58) as compared with 78in the 2 urban counties (220).

In Oklahoma, in 1987, the pharmacist-to-100,000 population ratio in rural counties was

67 compared with 72 in urban counties (451). In Nebraska, in 1981, 52 percent of all activepharmacists were located in the State’s 4 urbancounties (429). This distribution closely paral-lels that of Nebraska’s resident population, 53percent of whom resided in urban counties in1986 (631).

Optometrists

National SupplyThe active optometrist-to-100,000 population ratio

increased from 8.9 in 1970 to 10.6 in 1988. BHPrprojects that the ratio will increase to 14.2 activeoptometrists per 100,000 residents by 2020 (table10-50) (673).

The number of applicants to schools and collegesof optometry peaked in 1975-1976 and has declined

continuously since then (671). Enrollments in-creased until 1985 86 but have since leveled off

Box 10-F—Provider Profile: Optometrists

Optometrists examine, diagnose, and treat prob-lems of the eyes and vision system (673). Optome-try students must complete from 2 to 3 years of preoptometry higher education before entering a4-year program in optometry. On completion of undergraduate training, some optometrists enterspecialized residency programs in fields such as

family practice, primary care, geriatric, pediatric,and rehabilitative optometry (671).

Table 10-50-Supply of Professionally ActiveOptometrists, Selected Years: Estimated 1970-1988,

and Projected 1990-2020a

Active optometrists Number of active per 100,000

Year optometrists a people b

1970 . . . . . . . . . . . . . . 18,400 8.9

1980 . . . . . . . . . . . . . . 22,200 9.71988. . . . . . . . . . . . . . 26,100 10.61990 . . . . . . . . . . . . . . 27,100 10.82000 . . . . . . . . . . . . . . 33,100 12.32010 . . . . . . . . . . . . . . 38,800 13.72020 . . . . . . . . . . . . . . 41,700 14.2

aInc ludes optometrists in Federal service - bRatios based on total population, including Armed

Forces overseas, as of July 1.

SOURCE : U.S. Department of Health & Human Services,Health Resources and Services Administra-tion, Bureau of Health Professions, SeventhReport to The President & Congress on TheStatus of Health Personnel in The UnitedStates, DHHS Pub. No. HRS-P-OD-90-1 (Rock-ville, MD: HRSA, June 1990), table XI-A-1.

1980 to 1988, the median age fell from 49 to 41 years

(673). The proportion of all optometrists who are



y ( )creased until 1985-86 but have since leveled off (671,673); the number of graduates increased until1983-84, declined slightly in 1984-85, and hasremained relatively stable since that time (671,673).

The American Optometric Association (AOA)estimates that nearly three-fourths of the 25,400practicing optometrists in the United States in 1989were in independent practice, with the remainder

employed by HMOs, ophthalmologists, opticalchains, the Armed Forces, and other employers (56).The average age of optometrists is decreasing: from

( ) p p pwomen is expected to increase from 11.5 percent in1988 to 28.4 percent in the year 2000 (673). As forpharmacists, the Federal Government has ceased todesignate HMSAs for vision care providers (see ch.11).

Rural Supply

Optometrists are important providers of primary

eye and vision care in areas that lack ophthalmolo-gists. An analysis of 1983 registries of optometristsand ophthalmologists conducted by the AOA found

54~e &efiMn Association of C~He~~ of pticY, fi coopera t ion ~~ th e Natio~ Association of Bowds of P_cy, is currently p~pfig

to conduct another census. Rural/urban distributional information will be available from this census, but not for another 2 years (46@.




Table 10-51—Number of Cities With Optometrists and Ophthalmologists by State, 1983

Cities with Cities withState optometrists ophthalmologists Difference

a

Alabama. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alaska. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arizona. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arkansas. . . . . . . . . . . . . . . . . . . . . . . . . . . .California. . . . . . . . . . . . . . . . . . . . . . . . . .

Colorado. . . . . . . . . . . . . . . . . . . . . . . . . . . .Connecticut. . . . . . . . . . . . . . . . . . . . . . . . .Delaware. . . . . . . . . . . . . . . . . . . . . . . . . . . .District of Columbia . . . . . . . . . . . . . . . .Florida. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Georgia. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Hawaii. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Illinois. . . . . . . . . . . . . . . . . . . . . . . . . . . .Indiana. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Iowa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Kansas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kentucky. . . . . . . . . . . . . . . . . . . . . . . . . . . .Louisiana. . . . . . . . . . . . . . . . . . . . . . . . . . .

Maine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maryland. . . . . . . . . . . . . . . . . . . . . . . . . . . . Massachusetts. . . . . . . . . . . . . . . . . . . . . . . Michigan. . . . . . . . . . . . . . . . . . . . . . . . . . . . Minnesota. . . . . . . . . . . . . . . . . . . . . . . . . . . Mississippi. . . . . . . . . . . . . . . . . . . . . . . . . Missouri. . Montana. . . Nebraska. . Nevada. . . .

New Hampshire New Jersey New Mexico New York...

. . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .

North Carolina. . . . . . . . . . . . . . . . . . . . . . North Dakota. . . . . . . . . . . . . . . . . . . . . . . .Ohio.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Oklahoma. . . . . . . . . . . . . . . . . . . . . . . . . . . .Oregon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Pennsylvania. . . . . . . . . . . . . . . . . . . . . . . .Rhode Island . . . . . . . . . . . . . . . . . . . . . . . .South Carolina . . . . . . . . . . . . . . . . . . . . . .

South Dakota . . . . . . . . . . . . . . . . . . . . . . . .Tennessee. . . . . . . . . . . . . . . . . . . . . . . . . . .

101145592505

73104111

2071462449326176145119

116886710321825316681152497416

3829239

40017642

31310595

4073091

48124

275

2324254

275571

11650813

117513027

32342352979449263511136

2214816

212597

9124291621227

836

749

3268251

464940

9196163620912511592

8454445112115911755

117386110

1614423

18811735

2228166

2451864

4088



e essee. . . . . . . . . . . . . . . . . . . . . . . . . . .Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Utah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Vermont. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Virginia. . . . . . . . . . . . . . . . . . . . . . . . . . . . Washington. . . . . . . . . . . . . . . . . . . . . . . . . . West Virginia. . . . . . . . . . . . . . . . . . . . . . . Wisconsin. . . . . . . . . . . . . . . . . . . . . . . . . . . Wyoming . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total cities in U.S.... . . . . . . . . . . .

124273372811911780

20225

6,612

36951116524322528

2,459

881782612677458

15017

4,153

NOTE: Only communities with either an optometrist or an ophthalmologist are included in the count.aM1nimum number of cities where one or more optometrists were practicing in 1983J but where noophthalmologists were practicing in 1983.

SOURCE: F. Aron, Manager of Information and Data, American Optometric Association, St. Louis, M3, personalcommunication, 1989. Data were collected by hand counts of optometrists from American Optometric

Association, The Blue Book of Optometrists. 1984, 37th ed. (Chicago, IL: Professional Press, Inc.,1983) and of ophthalmologists from American Academy of Ophthalmology, The Red Book of Ophthalmology.

~, 35th ed. (Chicago, IL: Professional Press, Inc., 1983).

Chapter 10-The Supply of Health Personnel in Rural Areas .277

Table 10-52—Distribution of Optometrists byCommunity Population Size, 1989a

Community Percent of population size

b optometristsc

“Urban” (total). . . . . . . . . . . . . . . . . . . . .?.500,000 or more. . . . . . . . . . . . . . . . . .100,000-500,000. . . . . . . . . . . . . . . . . .25,000-100,000. . . . . . . . . . . . . . . . . . .

“Suburban” (total). . . . . . . . . . . . . . . . . .500,000 or more. . . . . . . . . . . . . . . . . .100,000-500,000. . . . . . . . . . . . . . . . . .25,000-100,000. . . . . . . . . . . . . . . . . . .

Under 25,000. . . . . . . . . . . . . . . . . . . . . . . .

TotalC

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40.7

13.212.914.6

24.82.96.015.9

34.4

100.0

aData based on approximately 1,100 rePlie5 to the

1989 American Optometric Association (AOA) EconomicSurvey, which was sent to a random sample of AOA

members. The AOA membership represents approximate-ly 75 percent of all practicing optometrists in the

United States. bcomnity population size was self-reported. It does

not necessarily reflect metro or nonmetro location.cpercentages may not add to 100 due to rounding.

SOURCE: American Optometric Association, St. Louis, MO, unpublished data from the 1989 AOAEconomic Survey provided to OTA in 1989.

professionals in the absence of adequate infer-mation (288).

Selected information on the educational preparation,employment, role, and regulatory environment of practitioners unselected AHP fields is summarizedin box 10-G.

Trends in the Supply of AHPs--An adequatefuture supply of AHPs will depend on changes inhealth care financing policies, technology, educa-

tional programs, and the regulatory environmentsth t ff t h t f AHP Of th l0 f i

In most other allied health fields--clinical labora-tory technology, dental hygiene, speech-languagepathology and audiology, respiratory therapy, anddietetic technology-supply and demand were ex-pected to remain fairly well balanced through theyear 2000, provided that downward trends in thenumber of graduates in certain professions are haltedand that improvements are made in salary andworking conditions (288).

Recent and projected trends in allied health fieldsinclude:

q

q

q

A 35 percent decrease in the number of graduates from clinical laboratory technologistprograms from 1982 to 1988, and a 25 percentdecrease in the number of graduates fromclinical laboratory technician programs from1982 to 1987 (673). A recent national survey

indicated a 54 percent undersupply of technolo-gists and a 38 percent undersupply of techni-cians.

61Other reports also indicate a marked

undersupply of these professionals in mostemployment settings (288).Increased demand for occupational therapists(OTs) during the past several decades (288,673),and a projected 52 percent increase in thenumber of OT jobs from 1986 to 2000 (288).

Short supply is linked to the limited number of training programs and the inability of thoseprograms to recruit faculty (288). IOM predictsa future shortage of OTs unless these condi-tions change (288). The number of OT gradu-ates did increase by 18 percent from 1982 to1988 (673).A projected 87 percent increase in the numberof jobs for physical therapists (PTs) from 1986to 2000 (288). Although the number of new PT

d h i d b i ll d i



that affect each type of AHP. Of the l0 professionsstudiedly IOM, physical therapists were most oftenreported as being in short supply (288). The IOMconcluded that, “barring major economic or healthcare financing contractions, the growth of thenumber of jobs for allied health workers willsubstantially exceed the nation’s average rate of growth for all jobs”. The growth rate is expected tobe highest for physical therapists and medicalrecords specialists. In the fields of physical therapy,radiologic technology, occupational therapy, andmedical record services, IOM indicated a potentialfor serious future imbalances in supply and demand.

q

q

graduates has increased substantially duringthe 1980s (673), supply may still not be able tokeep pace with demand.A 24 percent decline in the number of dentalhygiene graduates from 1980 to 1985 (thenumber increased slightly in 1986) (288).Strengthening entry requirements and increas-ing the length of training required may placefurther limits on the pool of interested students.Some areas have reported acute shortages of dental hygienists (288).A projected 45 percent increase in the numberof jobs for radiologic personnel from 1986 to

61B~ed on an infoIT@ s~ey of consti~ent societies conducted by the American Society for h’fedical ‘rechuoIogY (288).


Table 10-53-Estimated Supply of Selected Allied Health Personnel Employed in the United States:1970, 1975, 1980, and 1986, and Percent Change, 1975-86a b

Percent change,Occupation 1970 1975 1980 1986 1975-86

Total allied health personnel. . . . . . . .

Dental hygienist. . . . . . . . . . . . . . . . . . . . .Dental assistant. . . . . . . . . . . . . . . . . . . . .Dental laboratory technician. . . . . . . . .

Dietitian. . . . . . . . . . . . . . . . . . . . . . . . . . . .Dietetic technician. . . . . . . . . . . . . . . . . . Medical record administrator. . . . . . . . . Medical record technician. . . . . . . . . . . . Medical laboratory personnel: . . . . . . . .

Medical technologist. . . . . . . . . . . . . . .Cytotechnologists. . . . . . . . . . . . . . . . . . .

Medical laboratory technician. . . . . .Other laboratory personnel . . . . . . . . .

Occupational therapist. . . . . . . . . . . . . . .Physical therapist . . . . . . . . . . . . . . . . . . .Radiologic service worker. . . . . . . . . . . .

Respiratory therapist. . . . . . . . . . . . . . . .Speech pathologist/audiologist. . . . . . .Other allied health personnel.. . . . . .

673,000

15,000

112,000

31,000

17,0002,000

10,000

42,000

135,000

57,000

3,000

1,000

74,000

6,000

30,000

87,000

30,00019,000

135,000

899,

27,134,42,

23,3,12,53,

191,93,6,8,

84,21,38,97,

43,32,183,

000000000000

000000000000000000000000000000000000

000000000

1,100,00038,000156,00053,000

32,0004,00013,00064,000

249,000138,000

7,00013,00091,00025,00050,000

116,000

56,00042,000212,000

1,330,00048,000

175,00063,000

41,0007,00016,00076,000

293,000174,000

9,00016,00094,00032,00063,000

143,000

65,00057,000251,000

47

77

3150

781333343538750

10011526547

517837

aAll nufiers are rounded to the nearest thousand. Some numbers may differ from those that appear elsewheredue to revisions and independent estimations.

bIncludes only those personnel who have received certification/formal training in their particular alliedhealth field. Does not include on-the-job trained, noncertified personnel who may be employed innonregulated health care settings.

cInclude~, but is not limited to:dietetic assistants, general assistants, operating room technicians,

ophthalmic medical assistants, optometric assistants and technicians, orthopedic and prosthetictechnologists, pharmacy assistants, podiatric assistants, vocational rehabilitation counselors, other

rehabilitation services personnel, and other social and mental health services personnel.SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration. Bureau

of Health Professions, Sixth Report to the President and Congress on the Status of Health Personnelin the United States, DHHS Pub. No.HRS-P-OD-88-1 (Rockville, MD: HRSA, June 1988), table 12-1.

1990 (288). Severe shortages are likely to occurif the current downward trend in graduates isnot reversed. The number of graduates from

radiography programs decreased by 24 percentfrom 1981 to 1988, and the number of graduates

. A projected 75 percent increase in demand forcertified medical record technicians from 1986to 2000, due to the increasing complexity of the

tasks these personnel must perform (288). Afterchanges in Medicare hospital payment methods



, of gin nuclear medicine technology decreased by44 percent from 1984 to 1988 (673).

An increased demand for emergency medicaltechnician (EMT) paramedics in hospital emer-gency departments due to the recent nursingshortage (288). Estimating current supply and

predicting future supply of EMTs of all levelsof training are difficult, since most EMTs arevolunteers and no national data on the numberof graduates of training programs are availa-ble.

62

g p p yin 1983, hospitals reported substantially highergrowth rates unemployment of medical recordtechnicians and administrators than had beenseen in previous years. Demand for medicalrecords personnel in nonhospital settings isexpected to increase as well (288).

A national survey of hospitals conducted by theAmerican Hospital Association found that personnelvacancy rates were highest for PTs (16 percent) andOTs (15 percent) (673). A 1986 survey of 167Veterans’ Administration facilities found high va-cancy rates for PTs (23 percent), respiratory thera-

62FOrmOre fiomtionon walemergenqm~c~wrwme~ see OTA’s Special Report tmRural Emergency Medical Services (623).


Box 10-G—Provider Profiles: Allied Health Professionals (AHPs)

Clinical Laboratory Technologists/Technicians (CLTs)

CLT fields include generalist medical technology, blood bank technology, cytotechnology, hematology,histology, microbiology, and clinical chemistry (288). CLTs perform a wide array of tests used to help prevent,detect, diagnose, and treat diseases (673). Technologists are baccalaureate-prepared; technicians are associate-degree or certificate-prepared (288). Six States require technologists to be licensed (67.3); remaining States requireonly registration (288). Many CLT tasks are performed by nonlicensed, nonregistered individuals in unregulatedenvironments (e.g., private physician offices) (288). The Bureau of Labor Statistics estimates that, in 1988, 71

percent of CLTs were employed in hospitals (673).

Physical Therapists (PTs)

PTs must graduate from an accredited program before taking their licensure examination (288). Three typesof programs exist: baccalaureate programs, certificate programs for those with baccalaureate degrees in anotherfield, and 2-year master’s degree programs (288). PTs plan and administer treatment to relieve pain, improvefunctional mobility, maintain cardiopulmonary functioning, and limit the disability of people suffering fromdisabling injuries or diseases (67.3). All States require licensure for PT practice (673). In 1986,38 States allowedPTs to evaluate patients without physician referral, and 14 States allowed PTs to treat patients without physicianreferral (288). In 1986,40 percent of PTs worked in hospitals and 15 percent in independent or group practice (288).

Occupational Therapists (OTs)

OTs are trained through baccalaureate programs, post-baccalaureate certificate programs, or masters’ programs(673). OTs work with disabled individuals to help them learn the skills necessary to perform daily tasks, diminishor correct problems, and promote and maintain health. In 1989, 35 States and the District of Columbia requiredlicensure, 3 States required registration and had competency standards, and 4 States required certification for OTpractice (673). In 1986, 35 percent of OTs worked in hospitals, 17 percent in schools, 10 percent in rehabilitativefacilities, and the remainder in long-term care and home health settings (288).

Respiratory Therapists (RTs)

Accredited RT programs, which have grown in number in recent years, provide 2 years of training and granteither associate or baccalaureate degrees, depending on the student’s previous educational background (673). RTsprovide services ranging from emergency care for stroke, drowning, heart failure, and shock to temporary relief forrespiratory disorders. They also treat patients after surgery to prevent respiratory illness (288,673). Certification isvoluntary (673). In 1987, 18 States licensed respiratory care personnel, and licensure bills had been introduced in10 others (288). In 1986, almost 90 percent of RTs worked in hospital settings, and the remainder were employedin nursing and home health facilities. Forty percent of RTs are men—a larger proportion than in many other alliedhealth fields (288).

Dental Hygienists

Accredited hygienist programs include associate degree programs requiring 2 or more years of training andbaccalaureate degree programs requiring 4 years of training (288). Dental hygienists remove stains and deposits



baccalaureate degree programs requiring 4 years of training (288). Dental hygienists remove stains and depositsfrom patients’ teeth, take and develop x-ray films, apply fluoride, and make impressions of teeth. In some States,they may apply sealants to teeth, administer local anesthesia, and perform periodontal therapy. Licensure is requiredin all States. In most States, hygienists are required to work under the supervision of a dentist. The profession hasbeen striving for greater autonomy, and legislation recently passed in Colorado allows dental hygienists to practiceindependently (288). In 1986, 99 percent of dental hygienists were women and over 90 percent were under age 44(673). Ninety-five percent were employed in private dentists’ offices (673).

Dietitians

Dietitians are baccalaureate-prepared professionals who have completed special courses in nutrition and havecompleted the practical training required by the American Dietetic Association for registration (288). Dietitiansassess the nutritional needs of hospital patients and implement special diets. They also provide dietary counselingto groups and individuals. All certified dietitians must pass a national registration exam and participate in continuingeducation programs in order to maintain certification (288). Eight States require licensure, 5 require certification,

continued on next page

20-810 0 - 90 - 10 Q L 3


Box 10-G—Provider Profiles: Allied Health Professionals (AHPs)--Continued

and 3 require registration for the practice of dietetics (673). Most dietitians are employed in hospitals and nursingand personal care facilities (288).

Radiologic Technicians

The field of radiologic technology includes three distinct types of personnel. Radiographers receive 2 to 3

years of training in operation of x-ray equipment. They are licensed in 18 States (288). Radiation therapistsreceive 2 to 4 years of training and work primarily in oncology, preparing patients and administering ionizing radiationtherapy. Fifteen States licensed these personnel in 1987, and another 10 States had enabling legislation but nolicensure requirement. Nuclear medicine technologists receive 1 year of technical training in the use of radiopharmaceuticals in diagnosis and treatment. Seven States licensed these professionals in 1987, and another 10had enabling legislation but no licensure requirement. In 1986, 60 percent of all radiologic personnel worked inhospitals, but employment in freestanding diagnostic centers is expected to increase in the coming years (288).

Emergency Medical Technicians (EMTs)

There are three levels of EMTs, distinguished from one another by the extent of training involved (288). Allprograms are certificate-granting, and they are offered by police, fire, and health departments as well as by medicalschools, colleges, and universities. All 50 States have some type of certification procedure for EMTs, and 24 require

national registration for one or more of the 3 levels of EMT practice (288). There were an estimated 65,200 paidEMTs in 1986, working in private ambulance services, hospitals, and police and fire departments (288). However,roughly two-thirds of EMTs are volunteers who work for rescue squads and local fire departments (288). In ruralareas, an even larger proportion of EMTs are volunteers (623).

Medical Records Personnel

Medical records administrator programs are bachelor degree-granting and are based in colleges and universities(288). Medical records technicians typically hold associate degrees from community college-based programs. Manylower-level medical records personnel are trained on the job. No mandatory registration exists, although medicalrecords administrators may choose to take a national registry exam. Three-fourths of all medical records personnel

are employed by hospitals; others work in HMOs, nursing homes, and medical group practices (288).Speech-Language Pathology and Audiology Personnel

To be certified, speech-language pathologists and audiologists must have completed a master’s degrees in theirfield, although many States permit non-certified, baccalaureate-prepared practitioners to work in public schoolsettings (288). Speech-language pathologists diagnose and treat speech or language disorders, and audiologistsdiagnose and correct hearing disorders. Increasing numbers of practitioners are entering independent privatepractice (288). Thirty-seven States require licensure for private practice in clinics or other nonschool settings (673).Over one-half of employed speech-language pathologists and audiologists in 1986 worked in schools, colleges, anduniversities, with the remainder in health care settings (288).

pists (16 percent) and radiation therapy technolo- phlebotomists, and laboratory assistants) was 16.5



pists (16 percent) and radiation therapy technolo phlebotomists, and laboratory assistants) was 16.5gists and technicians (15 percent) (673):

Surveys of AHP supply in a wider range of settings were conducted in North Carolina in 1986(445). The highest vacancy rate reported was forOTs (21.5 percent). The vacancy rate for PTsincreased from 8.7 percent in 1981 to 19 percent in

1986, and trends away from hospital employmentand towards self-employment were noted. Thevacancy rate for respiratory care personnel, 98percent of whom were employed by hospitals in1986, doubled from 1981 to 1986, from 9 to 18percent. The vacancy rate for medical technologystaff (medical technologists, medical technicians,

perrcent, an increase over 4.6 percent in 1981.Ninety-four percent of all medical technology staff vacancies reported were in hospitals. The vacancyrate for medical records personnel was 11.9 percent,and the lowest reported vacancy rate (8 percent) wasfor radiologic personnel (445).

Multiskilled AHPs--AHPs became increasinglyspecialized during the 1960s and 1970s due to rapidtechnological advancements in the health care field.During the 1970s, however, concern about thesupply of health professionals in rural areas led to anincreased emphasis on the need for AHPs with skillsin more than one field. Surveys have found that


Table 10-54-Provider-to-Population Ratios for Selected Allied Health Professions byMetropolitan/Nonmetropolitan Area, 1980

Number per 100,000 residents Nonmetro ratio as

a percentage ofOccupation Metro Nonmetro metro ratio

Dietitian. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.9 26.0 84%Speech therapist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.5 14.4 74

Health aide (excludes nursing aides). . . . . . . . . . . 138.5 99.9 72

Inhalation therapist. . . . . . . . . . . . . . . . . . . . . . . . . . .23.1 16.6 72Dental assistant. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.2 53.2 71Health record technician . . . . . . . . . . . . . . . . . . . . . . . 7.2 5.0 69Radiologic technician. . . . . . . . . . . . . . . . . . . . . . . . . .46.3 31.0 67

Physical therapist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.1 12.7 60Clinical laboratory technician . . . . . . . . . . . . . . . . . 120.5 68.9 57

Dental hygienist. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.1 12.3 53Occupational therapist . . . . . . . . . . . . . . . . . . . . . . . . . 9.3 3.5 38

SOURCE: Adapted from Institute of Medicine, Allied Health Services: AvoidingCrises (Washington, DC: National Academy Press, 1989), table 6-4.

many hospitals use multiskilled AHPs (130,358a,424),and that many more would do so if they wereavailable (424). Training for multiskilled AHPsranges from formal training programs that offer dualcertification eligibility to informal on-the-job train-ing. The range of skill combinations reported byhospitals that use multiskilled workers is great, butthe three most common combinations are:

1. Respiratory therapist or technician and electro-encephalography or electrocardiography tech-nician;

2. Radiologic technologist and ultrasound tech-nician; and

3. Laboratory technologist or technician andradiographer (424).

No national data on the supply of multiskilled AHPsare available. Survey data indicate that most multi-

skilled AHPs are employed in small not-for-profitand small non-Federal government hospitals (424).

technicians, and dental hygienists (288). The greaterconcentration of health care facilities in urban areasmay explain some of the differences, but somedisparities--e.g., those among OTs--are too great tobe explained so simply. The reportedly wide use of noncertified personnel to perform AHP tasks innonregulated environments (e.g., private physi-cians’ offices) further confuses assessment of trueAHP availability and distribution. Anecdotal evi-

dence suggests that the most severe shortages of AHPs in rural health care facilities nationally are forPTs and OTs (162,462,473), although individualrural facilities report shortages for a wide array of AHPs.

A 1989 survey of small rural hospitals in Florida(572) found high vacancy rates for general radiogra-phers (20 percent), laboratory supervisors (16 per-

cent), laboratory technologists (13 percent), andrespiratory therapists (8.6 percent). A large propor-



g pA recent study identified only 75 programs in theUnited States offering formal cross-training, butinformal training for multiskilled AHPs has mostlikely been occuring for some time (424).

Rural Supply

Information regarding the national rural/urbandistribution of AHPs is similarly scarce, and theavailable national data are noncurrent. Table 10-54shows the rural/urban distribution of selected AHPsin 1980. Personnel-to-population ratios were lowerin rural areas in every AHP category and wereespecially low for PTs, OTs, clinical laboratory

p y p ( p ) g p ption of hospitals reported difficulties recruiting thesepersonnel; PTs and physical therapy technicianswere also often difficult to recruit. Rural hospitalshad sharply higher vacancy rates than did their urbancounterparts for laboratory and radiology personnel,but they had slightly lower rates for respiratorytherapists (572).

Rural facilities often cannot support highly spe-cialized AHPs on a full-time basis due to smallpopulation bases and low patient volume (see chs. 7and 12). Precarious financial conditions make itdifficult for some rural health facilities to competefor AHPs in the national labor market by raising


salaries and offering other incentives. Strategies thathave been suggested to overcome some of thesebarriers and ensure the adequate supply of AHPs inrural areas include:

encouraging the development of multiskilledAHPs through training and increased flexibilityof licensure laws for rural facilities,increased recruitment of students from rural

areas who may be more likely to return to thoseareas to practice,increased opportunities for training at ruralsites, andemployer-initiated cooperative hiring of AHPstaff by several health care facilities (288).

SUMMARY OF FINDINGS

Physicians

Overall physician supply has increased substan-tially over the past two decades. The number of MDsrelative to the U.S. population more than doubledbetween 1963 and 1988—from 146 to 237 per100,000 residents. The primary care specialties(particularly general and family practice) have

seen the lowest increases. From 1979 to 1988, the

number of primary care physicians per capitaincreased by 17.2 percent, compared with 30.2percent for nonprimary care physicians.

Primary care physicians are twice as likely asnonprimary care physicians to practice in rural areas,but this may change due to recent increases indemand for primary care physicians in urban set-tings. Rural areas rely heavily on primary care

physicians. In rural counties with fewer than 10,000residents, for example, primary care physiciansconstitute 81 percent of all professionally active

time than do their urban counterparts to obtainmedical care from physicians.

In 1988, all of the 111 counties (with a total resident population of 325,100) with no MD or DOwere rural. In 1988, 29 percent of all rural

residents were living in federally designated primary care HMSAs, compared with only 9.2 percent of urban residents (see ch. 11). Over 4,000 primary

care physicians would be needed to eliminateshortages in these urban and rural HMSAs.

Despite increases in the proportion of physicianswho are young (under age 35) in both rural and urbanareas, rural physicians are still older than their urbancounterparts. Most physicians in small rural countiesare in solo practice.

Some rural areas rely heavily on DOS. Although

they made up only 9.4 percent of the total U.S.physician population in 1986, DOS makeup as muchas 74 percent of total physician supply in someStates’ small rural counties.

Evidence suggests that the current supply of physicians in small rural counties is unstable. Newmedical graduates are increasingly indicating apreference for practice in large cities and suburbs,with fewer indicating a preference for small town

and rural practice sites.

Midlevel Practitioners

Midlevel practitioners can provide primary medi-cal care services in areas where no physician isavailable. NPs are about as likely as primary carephysicians to practice in rural areas. The proportionof NPs who are in rural areas seems to be decreasing.

The belief that PAs are more likely than physi-cians to locate in rural areas cannot be confirmed



constitute 81 percent of all professionally activephysicians. Future national shortages of primary care specialists are therefore likely to have a disproportionately negative effect on rural areas.

The increasing supply of physicians has resultedin greater physician availability in counties of allsizes. However, overall increases in physician-to-

population ratios have been lowest in the leastpopulated counties. In 1988, rural counties still hadfewer than one-half as many patient care MDs percapita as had urban counties. Rural counties withfewer than 10,000 residents had fewer than one-fourth as many patient care MDs per capita as urbancounties. Rural residents travel for longer periods of

because data on the rural/urban distribution of PAsare not available. The limited data available, how-ever, suggest that the proportion of PAs practicing insmall communities (under 10,000 residents) isdecreasing. This is also true for CNMs. This shiftmay be due to an increased demand for theseproviders in urban settings.

On the national level, evidence suggests thatcurrent demand for NPs and PAs exceeds currentsupply.

CRNAs, who provide nearly 70 percent of anes-thesia services in rural areas, are crucial members of the rural health care team in many hospital settings,


but their supply is in danger. Precipitous decreasesin the number of programs preparing CRNAs and thenumber of new CRNA graduates will adverselyaffect the future supply of CRNAs both nationallyand in rural areas.

Nurses

RN- and LP/VN-to-population ratios are pro-

jected to decrease in coming years. The number of graduates from nursing programs has already begunto decrease, and this trend is expected to continue.RN-to-population ratios are the lowest in the South,Mountain, and Pacific regions. Furthermore, theproportion of employed RNs working in rural areashas decreased in recent years, and rural health carefacilities may have increasing difficulty competingwith urban facilities in RN recruitment.

While the number of RNs employed in hospitalshas been increasing, the number of LP/VNs has beendecreasing. Rural hospitals have markedly fewerRNs and higher RN-to-LP/VN ratios than do theirurban counterparts. Analysis of regional nurse-to-population ratios shows that the regions with lowestRN availability are those with highest LP/VNavailability, indicating that LP/VNs may be substi-tuting for nurse positions that would otherwise be

filled by RN.

Data on RN shortages (e.g., vacancy rates) arelimited to the hospital and nursing home sector. RNsin smaller counties are more likely than RNs in largecounties to be employed in nonhospital settings, yetlittle is known about the adequacy of RN supply insuch settings.

Other Health ProfessionalsNumbers of practitioners in all other healthf i i d i hi h i d

rural counties (fewer than 2,500 residents) havingonly 15 office-based dentists per 100,000 residents.

The relative supply of general and pediatricdentists increased more in rural than in urban areasduring the 1980s. However, future constraints onnational supply due to recent and continuing de-creases in the number of dental graduates maychange this trend. There is a slight trend away fromgeneralist and towards specialist practice amongdentists; however, most dentists are still generalists.In 1987, 85 percent of dentists were in generalpractice, compared with 91 percent in 1970.

In 1988,183 counties had no general or pediatric dentist. Of these, 181 were rural counties of fewerthan 25,000 residents. An estimated 1,729 dentistsare needed to eliminate shortages in almost 800designated dental HMSAs, 72 percent of which are

in rural areas. Over 8 million people resided in ruraldental HMSAs in 1988.

Pharmacists

There are no data on U.S. rural pharmacist supply.State studies suggest that although some rural areashave few pharmacists, rural/urban differences inpharmacist distribution may not be as dramatic asthose for other health professionals. An increase in

the number of pharmacists relative to population isexpected over the next three decades, but growth indemand for pharmacists may exceed growth in thenational supply.

Optometrists

In many communities, optometrists are the onlyproviders of primary vision/eye care. Their rural/ urban distribution is not known, but a substantial

proportion (34 percent) practice in communities of 25,000 or fewer residents. Although the number of applicants to schools of optometry has declined in



professions examined in this report have increasedover the past two decades. Recent data on rural/ urban distribution are unavailable for most of theseprofessions. For some professions, even nationalsupply estimates are difficult or impossible to obtaindue to lack of data collection.

Dentists

The distribution of dentists parallels that of physicians. Rural counties have substantially fewerdentists per capita than urban counties (35 v. 58 per100,000 residents in 1987). Within rural counties,ratios decreased with county size, with the smallest

applicants to schools of optometry has declined inrecent years, enrollments have remained stable. Thesupply of optometrists relative to population isprojected to increase over the next two decades.

Allied Health Professionals

Physical therapists are in short supply nation-

ally, and the potential for serious future shortagesexists in the fields of physical therapy, radiologic technology, occupational therapy, and medical record services. In most other allied health fieldsstudied, downward trends in the number of trainingprograms and graduates will need to be reversed toavoid future shortages.


Although no recent national data are available onthe rural/urban distribution of AHPs, selected Statedata and anecdotal evidence suggest that ruralsettings currently have a disproportionately smallshare of AHPs, and they are likely to suffer morethan urban settings in the face of future shortages.Evidence from these sources further suggests thatsome rural facilities are facing critical shortages of physical and occupational therapists. Radiologic

and laboratory personnel are also in very shortsupply in some rural areas.

Multiskilled AHPs may be especially appropri-ate for small rural facilities. Although a smallnumber of formal training programs exist, nonational data on the supply of multiskilled AHPs areavailable.



Identifying

CONTENTS

Chapter 11

Underserved

Populations

q 287 INTRODUCTION

DESCRIPTION OF FEDERAL DESIGNATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287Health Manpower Shortage Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287Medically Underserved Areas/Populations q . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . , . . , . , 291Current Status of Federal Designations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

USES OF DESIGNATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296Federal Uses . . . . . . . s . . . . . . . . . . . . . . . . . . . . . . . . . . . . * . . . . . . . * # . . . . . . . * * * * * # * * . * * * . . * * . . + 296State Uses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

FEDERAL DESIGNATIONS: STATE ACTIVITY AND SATISFACTION .....,.,.......... 301HMSAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301MUAs . . . . . . . . . . . . . . . . . . . . q. . . .

. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . 304State Designation Capability ... ... ... ... ... ... ... ... ... ... ... ... * + * 4 . . ..**.`.** 306STATE SHORTAGE DESIGNATIONS: PREVALENCE AND USES . . . . . . . . . . . . . . . . . . . . ,.306HMSAs AND MUAs: PROBLEMS AND ALTERNATIVES 308



HMSAs AND MUAs: PROBLEMS AND ALTERNATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308Shortage Area Designations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Undeserved Area Designations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

Boxes Box

Page11-A. HMSA Designation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28811-B. MUA/P Designation Process ... ... ... ... ... ... ... ... ... ... *.. *.. . ++* +. #*.*.*****., 293

Figures Figure Page11-1. Health Manpower Shortage Areas (HMSAs), 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29611-2. Medically Underserved Areas (MUAs), 1981 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299

TablesTable Page

11-1. High Needs and Insufficient Capacity Criteria for Primary Care, Dental, and PsychiatricHealth Manpower Short Areas (HMSAs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

11-2. Criteria for Primary Care Health Manpower Shortage Area (HMSA) Priority Groups . . . 291

11-3. Basic Designation Criteria for Primary Care, Dental, and Psychiatric Health ManpowerShortage Areas (HMSAs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292

11-4. Application of the Index of Medical Underservice (IMU): Two HypotheticalExamples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294

11-5. Primary Care, Dental, and Psychiatric Health Manpower Shortage Areas (HMSAs):Number, Population, and Number of Providers Needed To Remove Designations,1979, 1985, and 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

11-6. Characteristics of Metropolitan and Nonmetropolitan Primary Care Health ManpowerShortage Areas (HMSAs), by Region and State, Sept. 30,1988 . . . . . . . . . . . . . . . . . . . . . . . 297

11-7. Medically Underserved Areas (MUAs) With Federally Supported Health Centers,by Region, 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

11-8. State Service and Shortage Criteria, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30111-9. Presence of State Health Personnel Distribution Programs That Use Shortage Area

Designations, 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30211-10. Changes in Designation Activity for Metropolitan and Nonmetropolitan Primary Care

HMSAs Since 1985.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30211-11. Factors Affecting the Demand for Federal Primary Care HMSA Designations

Since 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30311-12. State Satisfaction With the Federal Primary Care Health Manpower Shortage Area

(HMSA) Designation process, 1989. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30311-13. Changes in Designation Activity for Federal Medically Underserved Areas (MUAs)Since 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

11-14, Factors Affecting the Demand for Federal MUA Designations Since 1985 . . . . . . . . . . . . . 30511-15. State Satisfaction With the Federal Medically Underserved Area (MUA) Designation

Process, 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30511-16. Comparison of the Federal Index of Medical Underservice (IMU) and the

Michigan Primary Care Association (MPCA) Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30711-17, State Opinions on How Accurately Federal HMSAs and MUAs Reflect State Health

Personnel Shortages, 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

11-18. Shortage Area Designation Activity, by State, 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308



Chapter 11

Identifying Underserved Populations

INTRODUCTION

That rural areas have a relative lack of healthpersonnel is indisputable. Whether this differenceresults in inadequate access to health care is more

difficult to determine.The Federal Government uses two composite

measures for defining areas in which the populationhas inadequate access to health services. Areas,population groups, and facilities that lack sufficienthealth personnel, as measured by population-to-practitioner ratios, are termed “Health ManpowerShortage Areas” (HMSAs). Areas and populationgroups that have inadequate access to health care, as

measured by an index of four weighted indicators of health needs

l, are known as “Medically Under-

served Areas/Populations” (MUA/Ps). Although itis possible for an area to be designated both as anHMSA and as an MUA, the two Federal designa-tions are independently determined and must beapplied for separately.

This chapter summarizes the deve lopment and

uses of the Federal HMSA and MUA designationsand presents the results of an OTA survey examiningState activity and satisfaction with HMSAs andMUAs. (See app. D for a description of the survey.)In addition, the chapter examines the prevalence anduses of State shortage area designations. It concludeswith a discussion of the concepts of ‘shortage’ and“medical underservice” and a review of the litera-ture on alternative designation criteria.

DESCRIPTION OF FEDERALDESIGNATIONS

ment programs. Students in schools of medicine,osteopathy, dentistry, and optometry who served indesignated shortage areas could have all or part of their educational loans forgiven. Shortage areaswere designated by State health authorities accord-

ing to population-to-practitioner ratio criteria estab-lished by the Secretary of the Department of Health,Education, and Welfare (DHEW).

2Most of the

designations were at the county level (i.e., for wholecounties) and were in rural areas.

Legislation enacted in 1971 (Public Law 92-157,Section 332) extended the loan repayment programto cover non-Federal as well as Federal loans andshifted the responsibility for designating HMSAsfrom the States to the Secretary of DHEW. The 1971legislation added podiatrists, pharmacists, and veter-inarians to the list of eligible practitioners. The valueof the shortage ratio for each of the professionalgroups was established at approximately 150 per-cent of the national mean population-to-activepractitioner ratio for that group (except for physi-cians, where 200 percent of the national mean wasused). Using these cut-off points, about two-thirds of all U.S. counties were designated physician shortageareas and about one-half were designated dentistshortage areas.

A list of “Critical Health Manpower ShortageAreas” (CHMSAs) was compiled following thepassage of the Emergency Health Personnel Amend-ments of 1972 (Public Law 92-585). A population-to-primary care physician ratio of 4,000:1 was used to

identify either county or subcounty areas asCHMSAs. The list was used to place NationalHealth Service Corps (NHSC) personnel from 1974

3



Health Manpower Shortage Areas

History

The first Federal shortage area designations weremandated in 1965 (Public Law 89-290) for the

implementation of health professional loan repay-

to 1978.3

In 1976, Congress directed the DHEW (PublicLaw 94-484) to establish new criteria for designatingHMSAs that would:

. permit designation of urban as well as rural

areas;

l~e fow ~dicat~r~ ~~ed t. dete~e ~A~ me ti e ~ant mo~ity rate, th e percent of th e pop~tion 65 an d Older, tie Perwrlt of the pOpldaliOnliving in poverty, and the population-to-primary care physician ratio.

Whe population-to-practitioner ratios chosen as shortage levels for purposes of loan cancellation were 1,500:1 for physicians, 3,000: 1 for dentists,and 15,000:1 for optometrists. Special consideration was given to county or subcounty areas with inaccessible medical services, elderly or incapacitated

practitioners, and particular local health problems.

Ssee ch. 13 for a description of the IWSC pwwn.–~g’7–


Box 11-A—HMSA Designation Process

Requests for HMSA designation may be submitted to DHHS’s Office of Shortage Designation by anyindividual, project, or agency. Copies of the requests for designation are then forwarded to local and State healthplanning agencies, State Governors, State health departments, and appropriate professional associations for reviewand comment. Following the comment period, the Office of Shortage Designation completes its evaluation of therequest to determine if it satisfies the criteria for designation. Applicants are informed of the results of the evaluationby letter.

A record of all the designations made since 1978 is contained in a computerized file, the Shortage Area DataBase. This file is updated regularly to account for new designations, dedesignations, and changes in degree of shortage. By law, the list of HMSAs must be reviewed annually. Each year, DHHS sends the States the data it hason every county in the State and every designated primary care HMSA for the States to review. The States arenotified that all primary care HMSAs that are 3 years old or older will be redesignated unless the States supplyupdated information that warrants their continued designation (341). The most recent comprehensive review wasthe 1988-89 annual review, which emphasized the assessment of those primary care HMSA designations made ormost recently updated during 1985. Because very few resources are currently tied to dental and psychiatric HMSAs,these designations are updated less frequently than primary care HMSAs--usually on a case-by-case basis whena dentist or a psychiatrist is being placed (341).

DHHS periodically publishes lists of primary care HMSAs by State in the Federal Register. The most recentlist was published in November 1987 (52 FR 43992).

. broaden the concept of shortage to include groups, or 3) public or nonprofit private facilities.indicators of a need for health services such asinfant mortality, health status, and access tohealth services;

qpermit population groups and facilities experi-

encing health personnel shortages to be desig-nated; and

. establish priorities for assigning personnel toareas, population groups, and facilities withhigh needs (682).

The primary criterion for HMSA designation is stillthe population-to-practitioner ratio. The responsibil-ity for designations rests in the Health Resources andServices Administration’s (HRSA’s) Office of Short-

age Designation, within the Department of Healthand Human Services (DHHS).

5Box 11-A describes

the HMSA designation process.

Current Designation Criteria

Primary Care HMSAs—Primary care physiciansThe new criteria and designation, which replaced are defined for designation purposes to ‘include

CHMSAs, were published as final regulations in family and general practitioners. general pediatri-November 1980 (45 FR 75996-76010). They in-

.cians, obstetricians and gynecologists, and’ general

eluded separate criteria for each of seven types of internists. A geographic area may be designated ashealth manpower: primary care physicians, dentists, having a shortage of primary medical care personnelpsychiatrists, vision care providers, podiatrists, phar- if it

-

i t d t i i HMSA f thmeets the following criteria:



macists, and veterinarians. HMSAs were furthercategorized according to their degree of provider

q

shortage.q

The 1980 HMSA designation criteria are stillused, but HMSAs are currently being designated for

only three types of health professionals: primarycare physicians, dentists, and psychiatrists.4Under

the current regulations, HMSAs can be defined as: 1) q

urban or rural geographic areas, 2) population

4J3Wause of tie laclcof resources and resulting low des@nation activity, HMSAS for vision care providers, podiatrists, p-ckts,

are no longer routinely des@ated or updated. Des@ation of nursing shortage areas is accomplished under a separate legislativof the Public Health Service Act).

it is a ‘‘rational’ area for the delivery of primary medical care services;it has a population-to-primary care physicianratio of at least 3,500:1 (3,000:1 if the area has‘‘unusually high need’ for primary care serv-

ices or “insufficient capacity” of existingprimary care providers); andprimary medical care manpower in contiguousareas are overutilized, excessively distant, or

5~e Dep~ent of He~@ ~UcatiOq and Welfw was renamed the Department of lkdth ~d Hun Services ~ WY 1980.

Chapter 11--Identifying Underserved Populations q 289

otherwise inaccessible to the population of thearea under consideration (45 FR 76001).

An area qualifying as “rational” for the deliveryof primary medical care services need not conformto county boundaries; it may be part or all of a singlecounty, two or more counties, or an urban neighbor-hood. In some cases a rational service area mayextend across State as well as county boundaries.

Although service area size may vary due to differ-ences in population densities, HMSA criteria gener-ally require the population centers of counties orcontiguous counties seeking designation to be within30 minutes travel time of each other. Although thespecific definition of a rational service area is left upto the local applicant, Federal officials consider suchfactors as compactness, roads, natural barriers,sociodemographic and language barriers, and other

isolating features when reviewing applications fordesignation (682).

Primary care practitioner counts include all non-Federal doctors of medicine (MDs) and doctors of osteopathy (DOS)

6providing primary care in a

service area and contiguous areas. The number of fill-time-equivalent (FTE) primary care providers iscomputed to take into consideration the amount of time that is spent providing direct patient care (asopposed to administration, research and teachingduties) and to weight the care provided by interns,residents, graduates with foreign medical degrees,and practitioners who are semi-retired (45 FR76001).

An area with a population-to-primary care physi-cian ratio greater than 3,500: 1

7automatically quali-

fies for HMSA designation; an area with a ratio less

than 3,000:1 is automatically disqualified. Withinthat range, the area may qualify if unusuallyhigh-needs criteria (e.g., infant mortality and pov-

) i ffi i i i i (

oped to prioritize HMSAs so that scarce resourcescould be targeted to areas of highest need. Qualify-ing HMSAs are separated into four groups accordingto population-to-primary care physician ratios andindicators of high needs or insufficient capacity(table 11-2). The most critical shortage areas (group1 HMSAs) are those areas that have no physicians orhave a population-to-physician ratio greater than5,000:1 and an indication of high needs or insuffi-

cient capacity.

Specific population groups within geographicareas may be designated as primary care HMSAs if they meet the following criteria:

q

q

q

the area in which the population resides isrational for the delivery of primary medicalcare services;

access barriers (e.g., language differences)prevent the population group from using thearea’s existing primary medical care providers;and

the ratio of the number of persons in thepopulation group to the number of primary carephysicians serving the group is at least 3,000:1(45 FR 76002).

Eligible population groups might include those with

incomes below the poverty level, those eligible forMedicaid, medically indigent populations (definedas poverty population minus Medicaid eligibles),migrant workers and their families, native Ameri-cans, homeless populations, and other populationsisolated as a result of language, cultural barriers, orhandicaps. Population group designations differfrom geographic area designations in that physiciansnot serving the specific population group are ex-

cluded from physician counts (e.g., physicians notserving Medicaid patients are not counted in thedesignations of Medicaid eligibles). Population



erty rates) or insufficient-capacity criteria (e.g.,average waiting times for appointment and averagewaiting times at site of care) are sufficiently great towarrant the designation. (See table 11-1 for a list of the high-needs and insufficient-capacity criteria.)

Primary care HMSA priority groupings (alsocalled ‘‘degree of shortage groupings’ were devel-

group designations are made for partial-countyareas, but not for whole counties.

Public or nonprofit private medical facilities maybe designated as primary care HMSAs if they servedesignated areas or population groups and have

insufficient capacity to do so. Separate criteria areused for designation of Federal or State correctional

6Natio~ H~th se~ice COrpS (NHSC) commissioned corps and obligated persomel are not included in physician Counts. NHSc providers tie

counted if they decide to continue practicing in the area following completion of their obligated period of service. This presumably could cause the areato be redesignated.

7~e cmmt c~t~on of a 3,500:1 pop~tion.to_physici~ ra t io w= chosen b~ed on 1974 da m ~cau.$e it represented a level approximately 50

percent worse than the median county level and identifkd those counties that fell into the bottom quartile of population-to-physician ratios (682).


. .-IN

-Y

.

.

d N“m”

o40IDh

I&0)0-)u--lh

tia-

ulv



!+ N“ m

Chapter 11--Identifying Undeserved Populations q 291

Table 11-2—Criteria for Primary Care Health Manpower Shortage Area (HMSA) Priority Groups

Group Criteria if high needs Criteria if high needsare not indicated are indicated

1 No physicians No physicians or population greaterthan 5,000 per physician

2 Population greater than Population between 4,000 and 5,0005,000 per physician per physician

3 Population between 4,000 and Population between 3,500 and 4,000

5,000 per physician per physician4 Population between 3,500 and Population between 3,000 and 3,500

4,000 per physician per physician

a Are

as are considered as having “high needs”for primary health care services if they meet at least one of the

“unusually high needs”indicators ~ at least two of

SOURCE: Federal Rexister, vol. 45, p. 76002.

facilities. Like population group designations, facil-ity designations are made only for partial counties.

Dental and Psychiatric HMSAs--Criteria for thedesignation of geographic areas, population groups,and facilities as dental and psychiatric HMSAsresemble those for primary care HMSAs, with a fewimportant differences (see table 11-3). The mini-mum population-to-practitioner ratios, for example,are 5,000:l and 30,000:l for dentists

8and psychia-

trists, respectively. Unusually high-needs and insuffi-

cient-capacity criteria for these types of HMSAs alsodiffer from the primary care HMSA criteria (seetable n-1). Psychiatric facility designations maybemade for State and county mental hospitals as wellas for Federal and State correctional facilities.

Medically Underserved Areas/Populations

History

MUAs were authorized in 1973 by the Health

Maintenance Organization HMO) Act (Public Law93-222). HMOs drawing 30 percent or more of theirmembership from MUAs were to receive preferencef l f i iti l ti l t

9Th HMO

the “insufficient capacity” indicators.

tion, infant mortality, and health personnel wereselected because data for these factors were nation-

ally available and reliable (329). DHHS publishedthe IMU criteria for use in designating and prioritiz-ing MUAs in 1975 and 1976(40 FR 40315 and 41FR 45718).

Public Law 94-63 authorized grants to be made toprojects to plan, develop, or operate communityhealth centers (CHCs) that serve in designatedMUAs. In 1978, to eliminate the need to apply for

two separate designations pertaining to medicalunderservice, areas designated as primary careHMSAs were granted MUA designation status forthe purpose of meeting CHC funding criteria. In1980, these policies were repealed because HMSAdesignations were considered to be unstable andoverly dependent on small changes in numbers of physicians or local population characteristics (46 FR23817). However, the assumed greater “stability”

of MUA designations cannot be assessed, sincethese designations have never been reviewed on aregular basis.

F d l l i l ti d i P bli L 99 280



for loans for initial operational costs.9The HMO

legislation required the Secretary of DHEW todevelop explicit criteria for the designation of medical underservice. To do so, DHEW funded astudy that developed the Index of Medical Under-service (IMU) as the mechanism for determining

MUA status. Of the various indices of underserviceconsidered by the study panel for inclusion in theIMU, measures of poverty, agedness of the popula-

Federal legislation passed in Public Law 99-280enabled State governors to request designation forMedically Underserved Populations (MUPs) thatdid not meet MUA criteria. The first two Staterequests for MUP designations were published in theFederal Register in March 1987 (52 FR 7215). The

extension of the designation to specific populationgroups was prompted by situations such as thatdescribed by the Governor of Oregon in 1988, in

Wrdike the calculation of FTEprimary care physicians, the calculation of FTE dentists reflects productivity differences among dental practices basedon the age of the dentis~ the number of auxiliaries employed, and the number of hours worked per week.

NO new loans have been made or guaranteed under this provision since September 1986 (42 U.S .C. 300(e)).




which a community’s health access problems hadbeen exacerbated by an economic depression fol-lowing a decline in the timber and wood productsindustry (53 FR 10435).

In August 1989, the responsibility for MUA/Pdesignations was moved within the Bureau of HealthCare Delivery and Assistance from the Division of Primary Care Services, where grants to CHCs are

made, to the Office of Shortage Designation, so thatHMSA and MUA designations would be handled inthe same office. Box 11-B describes the MUA/Pdesignation process.

Current Designation Criteria

MUA Designations--MUAs are identified basedon their IMU score, which considers the followingfour factors:

1. infant mortality rate,2. proportion of the population over 65,3. proportion of the population with incomes

below the poverty level, and4. ratio of population-to-primary care providers.

The IMU score for an area is the sum of weightedvalues for each indicator (41 FR 45718). (See table11-4 for two hypothetical examples.) Values of theindex range from O to 100, with lower scoresindicating increasing medical underservice. The1975 median IMU score of all U.S. counties was 62,and that value was used as the cut-off point forunderserved areas. The geographic boundaries of MUAs may be county lines, or they may besubcounty boundaries such as townships and censustracts.

MUP Designations--MUP criteria have not yetbeen published. In general, MUP designations arebased on the application of the IMU and anevaluation of the unusual local conditions and access

Box 11-B—MUA/P Designation Process

The original set of MUA designations was madeby HRSA in 1976, based on a list of all U.S.counties and subcounty areas (including individualcensus tracts) that met the designation criteria (seetext). States did not have to request designations.The original list did not consider whether desig-nated areas were actually rational service areas(728).

The current MUA designation process requiresthat State agencies provide the Office of ShortageDesignation with data on the four IMU compo-nents. Where exact data are unavailable for smallgeographic areas and population groups, extrapola-tion methods may be used. MUPs may be requestedby State governors or local officials who submitdata on the IMU indicators as well as a description

of the unusual local conditions that affect thepopulation group. After undergoing an initial staff review, MUA and MUP requests are listed in theFederal Register to provide interested parties withan opportunity to comment. DHHS then makes afinal decision of whether to designate or deny therequest and informs the applicant of the results byletter.

12-year period. These predictions were based on theassumption that an increased supply of physicianswould result in corresponding increases in under-served areas.

Despite the predictions, the total number of designated HMSAs has actually increased since1982. As of December 31, 1988, there were 1,944primary care HMSAs (30 percent more than the1982 figure), 793 dental HMSAs, and 592 psychiat-ric HMSAs (table 11-5) (665). Of the primary careHMSA 67 t (1 307) l t d i l



evaluation of the unusual local conditions and accessbarriers that led to the recommendation for designa-tion in spite of failure to meet the IMU cutoff (728).

Current Status of Federal Designations

HMSAs

In 1983, HRSA projected that the number of counties that were wholly or partially designated asprimary care HMSAs would decline from 1,501 in1982 to 810 in 1994 (683). It also predicted that thenumber of primary care physicians needed to bringareas below the level of 3,500 residents per physi-cian would decrease from 5,076 to 3,204 during the

HMSAs, 67 percent (1,307) were located in rural(nonmetropolitan) areas. Of these rural HMSAs, 63percent (821) were group 1 or 2 HMSAs and 37percent (486) were group 3 or 4 HMSAs (665).

Although the number of people living in ruralprimary care HMSAs is slightly smaller than thenumber living in urban primary care HMSAs (16.5million v. 17.4 million), this population is a dispro-portionately large percentage of all rural residents.In 1988,29 percent of the U.S. rural population livedin designated primary care HMSAs, compared with9 percent of the urban population (table 11-5).


Table n-4-Application of the Index of Medical Underservice (IMU): Two Hypothetical Examples

County 1 County 2IMU criteria percent/ratioweight

a percent/ratioweight

a

Infant mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.40 24.8 17.30 19.5Population 65+. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.60 19.9 14.10 18.7Population below poverty. .....,. . . . . . . . . . . . . 7.3021.9 37.50 3.4Primary care physicians per 1,000 population. . . . . . . . . . . . . . . . . . . . . ..65 20,7 .15 2.8

IMU score. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87.3 44.4-----------------------------------------------------------------------------------------------

Qualifies as an MUA (IMU score < 62). . . . . . . . . . . No Yes

~eights that apply to the associated percent or ratio,as listed in the Federal Register (41 FR 45718).

SOURCE:Office of Technology Assessment, 1990.

Both the number of dental and psychiatric HMSAsand the population living in those areas were higherfor rural than for urban HMSAs. The disparity isespecially apparent for psychiatric HMSAs; inDecember 1988, 61 percent of the rural populationlived in designated psychiatric HMSAs (table 11-5).

Both the total number of primary care HMSAsand the percentage of primary care HMSAs that arein rural areas have been quite stable during the pastdecade (table 11-5). However, there has been someinstability among individually designated areas (i.e.,some areas have been newly designated and others

redesignated). Figure n-l illustrates the whole andpartial counties that qualified as rural primary careHMSAs in 1987.

Table 11-6 shows the number of urban and ruralprimary care HMSAs, the total population in pri-mary care HMSAs, and the number of physiciansneeded to remove designations, by region and State,as of September 1988. The South led the four regionswith both the largest total number of primary careHMSA designations (849) and the largest number of nonmetropolitan primary care HMSA designations(623) (666). One-half of the U.S. population in ruralHMSAs were living in the South

designation requests, especially for Medicaid eligi-bles and the medically indigent (340).

To the extent that factors such as the lack of

incentives and the lack of funds discourage areasfrom applying for Federal designations that wouldotherwise qualify, the number of designated HMSAsand MUAs underestimates the actual level of shortage. In 1986, for example, there were 95nonmetro counties with a physician shortage (popula-tion-to-physician ratio greater than 3500:1)

10that

were not designated as HMSAs, even though theywould presumably qualify (511). These counties

were concentrated in the South and North Centralregions. Also, since this analysis used county-baseddata, it did not capture partial-county areas that mayhave qualified for designation.

11

MUA/Ps

In 1981, the most recent year for which compre-hensive data are available, there were 2,440 desig-nated MUAs (both whole- and partial-county) (511).

Of these, 1,328 whole-county MUAs and 567partial-county MUAs were in rural areas (511) (seefigure 11-2). The highest proportion of whole-county MUAs were located in the South, and thehi h i f i l MUA



HMSAs were living in the South.

Population group designations accounted for 12percent of primary care HMSAs as of December 31,1988 (665); 22 percent of the urban primary careHMSAs and 8 percent of the rural primary care

HMSAs were for population groups (667). In thefuture, the Office of Shortage Designations expectsto see an increasing number of population group

highest proportion of partial-county MUAs werelocated in the North Central region (511).

These data on MUAs are not only outdated but areprobably inaccurate, due to the fact that the initialMUA designations did not assess whether identified

subcounty areas met the “rational service area”criterion (see box 11-B). Thus, some designatedareas may not actually be underserved. Updated

l~e~e ~ompuhtiom we based on he p~sence of doctors of medicine only and do not consider tie Presence of d~tors of osteoPa~Y.

llk 1$)88, # per~nt of all rural HMSAS were partial-county desi~tion.s (667).

Table 11-5--Primary Care, Dental, and Psychiatric Health Manpower Shortage Areas (HMSAs): Number, Population, and Number ofProviders Needed To Remove Designations, 1979, 1985, and 1988

a

December 31, 1979 June 30. 1985 December 31. 1988Number of Number of Number of

Population providers Population providers PopulationNumber of in needed to Number of

providersin needed to Number of in Percentage needed to

designated designatad remove designatad designated remove designated designatedHMSA type

of Us. removeq reas q raas desigations

b

q reaa q reas designationsb

q reaa areas populationc

designationsb

Primary care (total) . . . . . . 1,921 41,884,430 5,835 1,843 33,690,635 4,331 1,944 33,658,814 13.9Nonmetro. . . . . . . . . . . . . . . 1,350 19,010,058 2,587 1,314

4,10417,661,218 2,044 1,307 16,477,146 29.0 1,794

Metro . . . . . . . . . . . . . . . . 571 22,874,372 3,248 529 16,029,417 2,207 837 17,381,668 0.2 2,310

Dental (total). ., . . . . . . 916 20,952,631 2,442 777 16,814,930 1,715 793 1S,832,332 6.5 1,729

Nonmetro. . . . . . . . . . . . . . . 735 11,711,460 1,459 561 8,975,971 835 574 8,696,800 15.7 690Metro. . . . . . . . . . . . . . . . . 181 9,241,151 983 196 7,638,959 880 219 7,142,532 3.6 839

Psychiatry (total) . . . . ., 218 19,224,017 .- d 473 42,473,600 2,314 592 49,131,309Nonmetro. . . . . . . . . . . . d d

20.1 1,810160 -- -- 317 --c --c

d396 34,006,866 61.0

Metro. . . . . . . . . . . . . . . . . . d1,137

58 -- -- 156 --c --c 196 15,124,443 8.0 673

aThese figures Include all HMSAS (priority groups 1-4), including HMSAS in the U.S. possessions.b

The number of additional providers needed to redesignate all HMSAS, as follows: For primary care HMSAS, the number of additional primary care physicians (general/family practice, general internal medicine, general pediatrics, obstetrics/gynecology) required toachieve a population-to-primary care physician ratio of 3,500:1 (3,000:1 where high needs are indicated); for dental HMSAS, the numberof additional dentists required to achieve a population-to-dentist ratio of 5,000:1 (4,000:1 where high needs are indicated); for

psychiatry HMSAS, the number of additional psychiatrists required to achieve a population-to-psychiatrist ratio of 30,000:1 (20,000:1where high needs are indicated).

cBased on 1987 population estimates.4~ata not available.

SOURCES: U.S. Department of Health, Education and Welfare,Health Resources Administration, Bureau of Health Professions, Division ofHealth Professions Analysis,“Selected Statistics on Health Manpower Shortage Areas as of December 31, 1980,” Report No. 81-11, Rockville, MD, Feb. 26, 1981; U.S. Department of Health and Human Services,Health Resources and Services Administration,Bureau of Health Professions, Office of Data Analysis and Management,“Selected Statistics on Health Manpower Shortage Areasas of June 30, 1985,” Rockville, MD; U.S. Department of Health and Human Services ,Health Resources and Services

Administration, Bureau of Health Care Delivery and Assistance,ffice of Shortage Designation,“Selected Statistics on Health Manpower Shortage Areas aa of December 31, 1988,” Rockville,

MD; U.S. Department of Health and Human Servicea, HealthResources and Services Administration, Bureau of Health Professions,Office of Data Analysis and Management, Rockville, MD,unpublished data from the Area Resource File provided in 1989 and 1990.




Figure 11-l--Health Manpower Shortage Areas (HMSAs), 1987 (by nonmetropolitan county, 1986)

USES OF DESIGNATIONSincludes the most needy of the designated shortage

areas



areas.

Federal Uses

National Health Service Corps

The principal Federal program

designations is the National Health(NHSC), which places both volunteer and obligated The degree of shortage (priority grouping) of the

health care practitioners (mostly physicians) in HMSA is one of seven criteria that are used to

To be included on this vacancy list, a site must be

part of a system of care, be located in a currently

using HMSA designated HMSA, and need at least one FTE

Service Corm practitioner before it would be redesignated (664).13

lz~e Fe&~ Division of NHSC is IOca@j in HRSA’S Bureau of Health Care Delivery and Assktance (see app. ~.13R~~ p- ~We ~SAs needing less tit One ~ prac t i t ioner before d~esi~tion Wotid occur my be Considtied for the aSSi~ent Of nLUSe

practitioners, other midlevel practioners, and in some cases for the placement of a physician (664).


Table 11-6—Characteristics of Metropolitan and Nonmetropolitan Primary Care Health Manpower Shortage Areas(HMSAs), by Region and State, Sept. 30,1988

Number of physicians needed Number of primary care HMSAs

a

Total copulation in HMSAs to remove designationGeographic area Metro Nonmetro Metro Nonmetro Metro Nonmetro

United Statesc. . . . . . . 635

Northeast. . . . . . . . . . . . . . . . . 147 New England . . . . . . . . . . . . . 52

Connecticut . . . . . . . . . . 10

Maine . . . . . . . . . . . . . . . . 6 Massachusetts . . . . . . . . 24 New Hampshire . . . . . . . . 2Rhode Island . . . . . . . . . 8

Vermont . . . . . . . . . . . . . . 2

Middle Atlantic . . . . . . . . . 95 New Jersey. . . . . . . . . . . 12 New York. . . . . . . . . . . . . 46Pennsylvania . . . . . . . . . 37

Midwest . . . . . . . . . . . . . . . . . . 122East North Central . . . . . . 91

Illinois . . . . . . . . . . . . . 27Indiana . . . . . . . . . . . . . . 10

Michigan . . . . . . . . . . . . . 14Ohio. . . . . . . . . . . . . . . . . 29

Wisconsin . . . . . . . . . . . . 11

West North Central . . . . . . 31Iowa. . . . . . . . . . . . . . . . . 6Kansas . . . . . . . . . . . . . . . 2 Minnesota . . . . . . . . . . . . 8 Missouri . . . . . . . . . . . . . 10 Nebraska . . . . . . . . . . . . . 2 North Dakota . . . . . . . . . 2

South Dakota . . . . . . . . . 1South . . . . . . . . . . . . . . . . . . . . . 226

South Atlantic . . . . . . . . . . 107Delaware . . . . . . . . . . . . . 2Florida . . . . . . . . . . . . . . 35Georgia . . . . . . . . . . . . . . 21

Maryland . . . . . . . . . . . . . 8 North Carolina . . . . . . . 8South Carolina . . . . . . . 15

Virginia . . . . . . . . . . . . . 10 West Virginia . . . . . . . . 8

East South Central . . . . . . 49 Alabama . . . . . . . . . . . . . . 20Kentucky . . . . . . . . . . . . . 5 Mississippi . . . . . . . . . . 7Tennessee . . . . . . . . . . . . 17

West South Central . . . . . . 70

1,280

84240

171105

6003129

3191392427342727

180171417492126

36623219

132535

37292735

16228434843

242

17,173,563

4,509,819951,162130,424

40,178583,84733,618146,09517,000

3,558,657736,677

1,766,3041,055,6763,907,5463,387,7611,634,575

249,650657,229592,254254,053519,78576,78311,499

113,329258,75023,44931,006

4,9696,228,1262,995,959

49,6261,027,893

731,901274,757426,406264,723112,372108,281

1,318,070550,529131,501260,413375,627

1,914,097

14,183,882

741,387100,789

0

62,4465,3062,616

030,421

640,5980

325,671314,927

3,730,1082,118,938342,253392,380471,648610,626302,031

1,611,170218,021132,193129,870628,049149,437171,254

182,3467,836,8453,335,279

31,700392,995628,43472,169

775,498465,648469,809499,026

2,492,083528,478517,723808,425637,457

2,009,483

2305

41212022

5735

141

2923616393

577527268401018038

50709

3022

0864449

51801093737431424

16861233549

247

1570

77

14

0

90

1

0

4

63

0

31

32

454

29725

42

44

44

31

157

16

7

7

66

13

24

24771

344

1

55

665

93

34

38

52

237

46

70

60

61

190



Arkansas . . . . . . . . . . . . . 10Louisiana . . . . . . . . . . . . 19Oklahoma . . . . . . . . . . . . . 8Texas . . . . . . . . . . . . . . . . 33

37311688

, ,96,601

405,468170,813

1,241,215

, ,306,452713,31892,673

897,040

235525144

25

61

11

93

(continuedonnextpage)


Table 11-6-Characteristics of Metropolitan and Nonmetropolitan Primary Care Health Manpower Shortage Areas(HMSAs), by Region and State, Sept. 30, 1988-Continued

Number of physicians needed Number of primarycare HMSAs

a

Total population in HMSAs to remove designationGeographic area Metro Nonmetro Metro Nonmetro Metro Nonmetro

West. . . . . . . . . . . . . . . . . . . . . . 140 254 2,528,072 1,875,542 452 268 Mountain. ...,..... . . . . . . 40 167 350,255 1,283,060 87 190

Arizona . . . . . . . . . . . . . . 10 23 109,532 193,923 26 28Colorado . . . . . . . . . . . . . 8 19 67,787 83,410 9 12

Idaho . . . . . . . . . . . . . . . . 1 32 1,450 239,144 1 42 Montana . . . . . . . . . . . . . . 0 29 0 141,366 0 20 Nevada . . . . . . . . . . . . . . . 12 8 59,069 39,159 19 6New Mexico . . . . . . . . . . . 6 27 96,352 351,362 29 57Utah. . . . . . . . . . . . . . . . . 2 15 14,680 130,705 3 13Wyoming . . . . . . . . . . . . . . 1 14 1,385 103,991 0 12

Pacific . . . . . . . . . . . . . . . . . 100 87 2,177,817 592,482 365 78 Alaska . . . . . . . . . . . . . . 3 11 42,855 61,914 9 15California . . . . . . . . . . . 65 27 1,806,804 230,455 284 16Hawaii . . . . . . . . . . . . . . . 2 0 18,760 0 6 0Oregon . . . . . . . . . . . . . . . 20 31 161,303 113,379 31 23

Washington . . . . . . . . . . . 10 18 148,095 186,734 35 24

aIncludes geographic, population, and facility designations.bThis iS the number of additional primary care physicians needed to bring the Population-to-primarY care physician ratio below 3,500:1 (3,000:1 where high needs are indicated).cThese fi8ures d. not include ~SAs in the District of Columbia or in the U.S. Possessions.

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau ofHealth Care Delivery and Assistance, Office of Shortage Designation, Rockville, MD, unpublishedstatistics on Health Manpower Shortages as of September 1988, provided to OTA in 1989.

determine a site’s ranking on the vacancy list. The

seven criteria are:1.

2.

3.

4.

5.

infant mortality rate,

percent of population with incomes below 200percent of poverty level,

HMSA degree-of-shortage grouping,

percent minority population served by the siteor residing in the county where the site islocated,

percent special population (including home-less, migrant and seasonal farmworkers, peri-natal, persons with human immunodeficiencyvirus and acquired immunodeficiency syn-drome (AIDS) substance abusers and elderly

There is a separate vacancy list for each primary

care specialty and for emergency medicine (270).The opportunities vary by specialty. Family practi-tioners, for example, may get lists of relativelyisolated rural sites, while other primary care special-ists may get lists of placements in more populatedareas (716). Placements of obstetricians are madeonly in areas where an “established and well-functioning system of care with appropriate cross-coverage’’ exists (716).

The highest priority sites on each of the vacancylists become the “HMSA Placement OpportunityList” (HPOL)

14for that specialty. The number of



6.

7.

drome (AIDS), substance abusers, and elderlypersons) served by the site,

vacancies as a percent of total budgeted staff,and

degree of rurality (664).

A point system (O-4, with 4 indicating greatest need)is applied to each of the seven criteria, with the totalpoints indicating a site’s relative need and determin-ing its ranking on the vacancy list (664).

( ) p ysites on each specialty HPOL corresponds exactly tothe number of graduating scholarship recipientsavailable for placement in a given year. In 1991,there will be 74 obligated professionals available for

placement (716). The obligated NHSC participantsselect placements from the list and arrange inter-views. Negotiation for a placement occurs betweenthe NHSC participant and the community or organi-zation that has the vacancy.

14’1’’he~OLw~f~t~ed~ 1983fOl10w@~ngressiO~ hearings suggesting thatDHHS Wget~SC reSOUrcestO areaSOfgreateStneed (27~).


Figure n-2-Medically Underserved Areas (MUAs), 1981 (by nonmetropolitan county, 1986)

MUA Classification

_ Nonmetropolitan MUA Whole County

Nonmetropolitan MUA P ar t ia l Co u n tyO Nonmetropolitan Non-MUA

O Metropolitan County

SOURCE: T.C. Ricketts, Rural Health Research Center, University of North Carolina, Chapel Hill, NC, under eontract to the Office of Technology Assessment,1989. Data from the Area Resouree File, Bureau of Heatth Care Delivery and Assistance, Health Resources and Serviees Administration, U.S.Department of Health and Human Services.

Following the determination of the HPOL, a loanrepayment list is created from the sites remaining on

the vacancy list. The number of sites on the loanrepayment list is based on estimates of the numberof providers the Division of NHSC hopes to recruitunder the loan repayment program (the goal for 1991is 900 providers) (716). Finally, a volunteer vacancy

that only one-fourth of nonmetro whole-countyMUAs have a federally supported CHC or MHC,

and the great majority of these are in the South (table11-7) (511). Only 17 percent of nonmetro partial-county MUAs have a CHC or MHC.

Although HMSA and MUA designations were



list is determined that includes all the sites on thevacancy lists that are not included on the HPOL orloan repayment lists. (Volunteers may, of course,practice at a higher-priority site if they choose.)

Other Programs

MUA/P designations have primarily been used totarget Federal resources to CHCs and related pro-grams (e.g., Migrant Health Centers (MHCs)) (Pub-lic Law 94-63). However, existing data

15suggest

designed to meet the needs of the NHSC and CHCprograms, they have since been used to implementa number of other Federal programs as well. Thoselinked to HMSA designations include the provisionof funds for health professions training , the AreaHealth Education Center (AHEC) program, and theMedicare physician bonus payment program (see ch.13 for program descriptions). Both HMSAs andMUAs are used to target resources under the RuralHealth Clinics Act (Public Law 95-210). Providers

lsBmed on 1981 MUA data and 1989 CHC/MHC Wt$.

Table 11-7--Medically Underserved Areas (MUAs) With Federally Supported Health Centers, by Region, 1989a

Metropolitan NonmetropolitanType of health Whole-county Partial-county Whole-county Partial-county Region Facilitycenter in MUA Region Non-MUA MUA MUA Non-MUA MUA MUA totals totals

Community Northeast 4 1 39 0 9 19 72Health Center South 6 16 40 4 166 9 241(CHC) only Midwest 3 1 27 4 37 23 95

West o 0 16 8 28 8 60 468

Migrant Health Northeast 5 0 3 1 0 1 10Center (MHC) South 1 6 5 1 28 6 47only Midwest 2 0 7 9 1 7 26

West 2 0 4 9 6 4 25 108

Both CHC Northeast 2 0 10 0 1 0 13and MHC South 1 7 15 1 47 2 73

Midwest 2 0 10 4 3 6 25 West 2 0 27 6 5 9 49 160

None Northeast 26 1 26 22 5 42 122South 34 82 116 68 654 76 1,030Midwest 68 5 70 193 257 316 909West 13 0 11 139 81 39 283

Totals 1712,344

119 426 469 1,328 567

‘Centers data as of 1989; population as of 1986; MUAs as of 1981.

SOURCE: T.C. Ricketts, Rural Health Research Center, University of North Carolina, Chapel Hill, NC. Analysis of unpublished data(provided by the Health Resources and Services Administration) conducted under contract to the Office of Technology Assessment,1989 and 1990.




Table 11-8—State Service and Shortage Areas Criteria, 1986

Criteria Programs Statesa

Health Manpower Shortage Area (HMSA) . . . . . . . . . . . . . 16 14HMSA and/or Medically Underserved Area (MUA). . . . . 2 2

Modified HMSA b. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 4

Population-to- hC - u n i t y size$.ys~;;an.;at?osc ~

38

Anywhere in Statee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 8

State criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 4Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ 8 —

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 51

astate~ d. not total t. 50 because multiple programs in the State use the samecriteria

”Eight States with programs have no criteria.bMaryland, Maine, New Mexico,and North Carolina add their State and local health, mental health, andcorrections institutions to a list of acceptable practice sites.

ccounty-wide population-to-physician ratios are used by three StateS;

Kansas (3,000:1), Kentucky (4,500:1),and South Carolina (2,000:1).

dThe States with Progrms with placements according to comnunity siZe are Alabama (5,000 Population ‘aximm)~

Arkansas (8,000), Georgia (15,000), Illinois (35,000), Missouri (6,500), Mississippi (10,000), Oklahoma

(7,500), and Texas (30,000).‘Alaska, Arizona, Kansas (primary care specialists), Massachusetts, Maryland (except Montgomery County), Washington, West Virginia, and Wisconsin.fcalifornia, Illinois, New York, and Oregon.

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau ofHealth Professions, Office of Data Analysis and Management, Compendium of State Health ProfessionsDistribution Programs: 1986, DHHS Pub. No. HRP-0906964 (Washington, DC: U.S. Government PrintingOffice, 1986).

must be located in clinics in rural HMSAs or MUAsto qualify to receive cost-based reimbursement forMedicare and Medicaid services (see ch. 3). MostHMSA-linked resources are tied to the primary careHMSA designation.

State Uses

Many States have adopted programs to promotethe placement of health professionals in underservedareas (see ch. 12). Although some States have

developed their own shortage area designationcriteria, many States rely on Federal designations toidentify areas and populations in need.

Of 113 State health professions distribution pro-grams identified by the Federal Bureau of Health

shortage area designation (either an HMSA, MUA,or State designation) (table ll-9).

16HMSA designa-

tions were most frequently used to implementAHEC programs, service-contingent loans and schol-arships, health professions school loan repaymentprograms, and preceptorship. State designationswere most frequently used for service-contingentloans and scholarships, placement programs, andtargeted primary care training opportunities.

FEDERAL DESIGNATIONS: STATEACTIVITY AND SATISFACTION

HMSAs

Activity



grams identified by the Federal Bureau of HealthProfessions in 1986, 61 used some type of shortagearea criteria. About one-third of programs and Statesused the Federal HMSA criteria or slight modifica-tions of them (table 11-8).

Three-fourths of the 45 respondents to a 1989OTA survey of State HMSA/MUA activity (34States) indicated that their State had health person-nel distribution programs that used some type of

Activity

Interest in obtaining HMSA designations has notdeclined substantially despite a decline in thenumber of available NHSC personnel. In fact, in

OTA’s survey the percentages of States indicatingthat the demand for Federal primary care HMSAdesignations had increased or remained the same

since 1985 were 71 and 82 percent for urban andrural areas, respectively (table n-10). States indicat-

16Tenrc~POn&nt~ indi~t~d~t~eir s~tes~dnot~ve anyhe~~~rsonnel dis~butionpro~s using shortage area designations and OIE

respondent answered “don’tknow.”


Table 11-9—Presence of State Health Personnel Distribution Programs That Use Shortage AreaDesignations, 1989a

Program present Shortage designation usedc.

in State? b

StateState distribution programs Y N NR HMSA MUA designation

Educational programs Area Health Education Centers. . . . . . . . . . . . . . . . . 21 15 9 11 2 3Targeted primary care training opportunities

(e.g., residencies). . . . . . . . . . . . . . . . . . . . . . . . . 20 15 10 6 0 7

Seat purchases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 20 20 1 0 0Preceptorship. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 15 10 9 2 3

Other educational program . . . . . . . . . . . . . . . . . . . . . 2 15 28 1 0 0Financial incentives during training

Service-contingent loans and scholarships. . . . . 27 11 7 10 3 16Other loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 20 21 1 0 2Other scholarships . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 20 24 0 0 1Other financial incentive . . . . . . . . . . . . . . . . . . . . . 1 15 29 1 0 0

Aid in practicePlacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 15 14 6 2 9Guaranteed income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 21 22 0 0 0Loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 17 22 1 0 4

Health professions school loan repayment . . . . . . 13 19 13 10 4 4 Malpractice subsidy . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 20 20 1 1 2Other aid in practice . . . . . . . . . . . . . . . . . . . . . . . . . 3 14 28 1 1 2

Other programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 13 28 2 2 2

ABBREVIATIONS: Y = yes; N =no; NR= no response.aBased on 45 States responding to O’M’S survey of shortage and underserved areas (see aPP. ‘)”

bTen States reporting n. State health personnel distribution Progrms, and one resPondin5

included as “no” for each specific program.“don’t know,” were

Where States answered “yes” to some programs but left others blank, the blank responses were included in the “no response” column.C~SA WA and State designations used for a particular program do not alwaYs add uP to the n~er ‘

f‘

tates

indi;atin~ that the program was present in their State. Some States use more than one designation criteria

to implement programs, while other States did not indicate that any of the three criteria were used.


Table 11-10--Changes in Designation Activity for Metropolitan and Nonmetropolitan Primary Care HMSAsSince 1985 (as of 1989)a

Number (p ercent) of States that had:Increased No Decreased Don’t know/activity change activity does not apply

Total of States: Metro HMSAs. . . . . . . . . . . . . . . . . . . . 12 (27%) Nonmetro HMSAs. . . . . . . . . . . . . . . . . 26 (58%)

Within regions:

Northeast (7 States) Metro HMSAs. . . . . . . . . . . . . . . . . . . 0 ( O%)

20 (44%)11 (24%)

4 (57%)

11 (25%)

7 (16%)

2 (29%)

2 ( 4%)1 ( 2%)

1 (14%)



Nonmetro HMSAs. . . . . . . . . . . . . . . . 2 (29%)South (16 States) Metro HMSAs. . . . . . . . . . . . . . . . . . . 6 (38%) Nonmetro HMSAs. . . . . . . . . . . . . . . . 11 (69%)

Midwest (11 States) Metro HMSAs. . . . . . . . . . . . . . . . . . . 1 ( 9%) Nonmetro HMSAs. . . . . . . . . . . . . . . . 5 (46%)

West (11 States) Metro HMSAs. . . . . . . . . . . . . . . . . . . 5 (46%) Nonmetro HMSAs. . . . . . . . . . . . . . . . 8 (73%)

2 (29%)

5 (31%)

1 ( 6%)

8 (73%)5 (46%)

3 (27%)

3 (27%)

3 (43%)

4 (25%)3 (19%)

2 (18%)1 ( 9%)

3 (27%)

o ( o%)

o ( o%)

1 ( 6%)

1 ( 6%)

o ( o%)o ( o%)

o ( o%)o ( o%)

aBased on 45 States responding to OTA’S survey of shortage and underserved areas (see aPP. D).



Table 11-1 l—Factors Affecting the Demand for Federal Primary Care HMSA Designations Since 1985 (as of 1989)a

Number (Percent) of States that had:Increased Decreased Had no Don t No

Factor demand demand effect know response

Need for NHSC personnel. . . . . . . . . . . . . 31 (69%) 5 (11%) 6 (13%) 3 ( 7%) o ( o%)

Availability of NHSC personnel. ...., 15 (33%) 23 (51%) 5 (11%) 2 ( 4%) o ( o%)Rural Health Clinics Program . . . . . . . . 19 (42%) 1 ( 2%) 11 (24%) 13 (29%) 1 ( 2%) Medicare physician bonus payment. . . . 26 (58%) o ( o%) 7 (16%) 12 (27%) o ( o%)State programs linked to HMSAs. . . . . . 18 (40%) o ( o%) 19 (42%) 5 (11%) 3 ( 7%)

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 (22%) o ( o%) 1 ( 2%) 2 ( 4%) 32 (71%)

ABBREVIATIONS:HMSA = Health Manpower Shortage Area;HSC = National Health Service Corps.

aBased on 45 Stetea responding to OTA’S survey of shorta8e and underserved areas (see aPPo ‘)”


Table 11-12—State Satisfaction With the Federal Primary Care Health Manpower Shortage Area (HMSA)Designation Process, 1989a

Number (Percent) of States that were:

Satisfied Dissatisfied Don’t know/no opinion No response

Criteria . . . . . . . . . . . . . . . . . 28 (62%) 16 (36%) 1 ( 2%) o ( o%) Application process

b. . . . . 32 (74%) 11 (26X) o ( o%) o ( o%)

Review process. . . . . . . . . . . 30 (67%) 13 (29X) o ( o%) 2 ( 4%)

aBased ~ 45 states responding to OTA’S survey of shortage and underserved areas (see aPP. D).b~e t= States that have not filed an HMSA application since 1985 were not asked to evaluate the application

process. Thus the total number of States answering this question was 43.


ing an increase in designation activity were mostlikely to be located in the South or the West.Forty-three of 45 responding States had filed at least1 HMSA application since 1985, but trends indesignation activity varied considerably amongStates.

Factors cited most often as contributing to in-creased demand for HMSAs since 1985 were:

need for NHSC personnel (31 States);Medicare physician bonus payment (26 States);Rural Health Clinics program (19 States); andState programs linked to HMSA designations(18 States) (table 11-11).

workable. Aspects of HMSA criteria that respon-dents thought were good and should be retainedincluded:

q

q

q

q

q

q

high needs criteria (9 States),population-to-physician ratio (7 States),consideration of distance and travel conditions(6 States),the ’’rational service area” concept (estates),

consideration of contiguous area resources inassessment of the availability of physicians (3States), andfocus on special population groups (estates).

For the substantial minority of States (36 percent)



Ironically, the factor cited most often as decreasingHMSA demand activity was the availability of NHSC personnel (23 States).

Satisfaction With HMSA Designations

Criteria-In OTA’s survey, most States (62percent) were satisfied with the criteria used todesignate Federal primary care HMSAs (table 11-12). overall, respondents indicated that HMSAcriteria were generally relevant, well-defined, and

y ( p )that were dissatisfied with the criteria, the mostcommon criticism was that the present cut-off pointof 3,500:l for the population-to-primary care physi-cian ratio is too high (13 States). Suggested cut-off

points ranged from 2,000:1 to 3,000:1. Relatedsuggestions to improve the identification of primarycare personnel shortage areas concerned the produc-tivity and actual availability of physicians counted.Three respondents suggested discounting elderlyphysicians before they retire. Several respondentssuggested excluding physicians whose services are




Table 11-13-Changes in Designation Activity for Federal Medically Underserved Areas (MUAs)Since 1985 (as of 1989)a

Number ( percent )of States that had:Increased No Decreased Don’t know/ Noactivity change activity does not apply response

Metro MUAs. . . . . . . . . . . . . . . . 4 (9%) 12 (27%) 12 (27%) 10 (22%) 7 (16%) Nonmetro MUAs. . . . . . . . . . . . . 3 (7%) 14 (31%) 11 (24X) 10 (22%) 7 (16%)

aBased on 4S States responding to OTA’s survey of shortage and underserved areas (see aPP. D).


Table 11-14—Factors Affecting the Demand for Federal MUA Designations Since 1985 (as of 1989) a

Number ( percent) of States that had:Increased Decreased Had no Don’t No

Factor demand demand effect know response

Need for CHCs. . . . . . . . . . . . . . . . . 14 (31%) o ( o%) 15 (33%) 5 (11%) 11 (24%) Availability of CHC funds . . . . . 7 (16%) 11 (24%) 12 (27%) 5 (11%) 10 (22%)

Rural Health Clinics Program. . 9 (20%) o ( o%) 16 (36%) 9 (20%) 11 (24%)State programs linked to MUA designation. . . . . . . . . . . . . 3 ( 7%) o ( o%) 22 (49%) 5 (11%) 15 (33%)

Other . . . . . . . . . . . . . . . . . . . . . . . . . 0 ( o%) 1 ( 2%) o ( o%) o ( o%) 44 (98%)

ABBREVIATIONS: CHCS = C oaxnunity Health Centera; MUA = Medically Underserved Area.aBased on 45 States respnding to OTA’S survey of shortage and underserved areas (see aPP. D).


Table 11-15--State Satisfaction With the Federal Medically Underserved Area (MUA) Designation Process,1989’

Number ( percent) of States that were:Satisfied Dissatisfied Don’t know/no opinion No response

Criteria. . . . . . . . . . . .......12 (27%) 16 (36%) 15 (33%) 2 ( 4%)Application process . . . . . . 2 (11%) 9 (50%) 6 (33%) 1 ( 6%)Review process . . . . . . . . . . . . 2 ( 4%) 20 (44%) 16 (36%) 7 (16%)

a~ased on 45 states respnding to OTAIS survey of shorta6e and underserved areas (see aPP. ‘)”bme 27 States that had not filed an WA application since 1985 were not asked to evaluate the application

process. The total number of States responding to this question was 18.


q

q

updating the weighting factors attached to thefour indicators of need (8 States),considering combining HMSA and MUA des-i ti i t (7 St t )

. reexamining the current applicability of theIMU cut-off score used to distinguish an MUAfrom a non-MUA (2 States).



q

q

ignations into one measure (7 States),incorporating factors that might be affectingaccess to care (e.g., the percentage of thepopulation that is uninsured, on Medicaid, or a

member of a minority) (6 States),replacing some criteria with other measures(e.g., low birthweight percentage instead of infant mortality, unemployment rates or per-sonal income instead of poverty rates, and ratesof chronic disease instead of percentage of elderly) (estates), and

Two States mentioned that the weighting factorsassociated with the proportion of the population thatis elderly and the infant mortality rate tend to cancel

each other out. Designating frontier areas wasreportedly five States to be a problem.

Application and Review Processes--Of the 18States that had filed an MUA application since 1985,9 reported dissatisfaction with the application proc-ess (table 11-15). Four respondents noted that theyhad received no response to designation requests and


cited poor communication with Federal staff as aproblem.

Most respondents who expressed an opinion weredissatisfied with the frequency of review (table11-15), with suggested frequencies ranging fromannually to every 3 to 5 years. Three States believedthe optimal frequency would depend on the specificsof new modified MUA designation criteria and howresources were tied to MUA status.

Thirteen States suggested that criteria used forreviewing MUAs that have CHCs or other federallyfunded services should differ from criteria used forother MUAs. Several States raised the concern thatwhen CHCs have a favorable impact (e.g., reduceinfant mortality), this jeopardizes their MUA desig-nation status. One respondent suggested that differ-ent MUA criteria be developed for initial designa-tions and for those areas seeking redesignation.

State Designation Capability

OTA’s survey also examined the opinions of therespondents regarding how well-equipped they wereto conduct shortage designation activity in theirStates. Nearly three-fourths of respondents (33 of 45) reported that the withdrawal of Federal planningresources had a negative effect on the States’ ability

to prepare requests for HMSA/MUA designation.Respondents overwhelmingly linked the lack of staff available to prepare requests for designations tothe withdrawal of Federal funds. The majority of respondents (35 States) reported that State andFederal resources were not adequate for maintainingan accurate and up-to-date list of health personnelshortage areas and medically underserved areas.

STATE SHORTAGEDESIGNATIONS: PREVALENCE

AND USES

Federal HMSA and MUA designations provide acentralized and relatively uniform designation sys-

States (22 of 45), either alone or in conjunction withHMSA or MUA criteria, to implement State healthpersonnel distribution programs. In describing crite-ria, two States reported that they used modifiedHMSA designation criteria, four States used specialty-specific population-to-provider ratios, and twoStates used a population-to-primary care physicianratio that was lower than the HMSA cut-off of 3,500:1. Another criterion used by two States wascommunity size (e.g., an area could qualify if it hadfewer than 15,000 or 10,000 residents).

A few States have developed more elaborateindicators of medical underservice. Michigan, forexample, has expanded on the IMU to develop a newmodel designed to be more responsive to Stateeconomic conditions (386). The Michigan PrimaryCare Association (MPCA) model added two newvariables (percentage of persons eligible for Medi-

caid and the aggregate unemployment rate) to theIMU and has a revised system of weights (table11-16). The MPCA model puts the greatest empha-sis on poverty and Medicaid eligibles, while theIMU emphasizes population-to-primary care physi-cian ratios and infant mortality. The MPCA intendsto use its model as one of the criteria in a Stateprogram to place physicians, nurse practitioners, andnurse-midwives in areas of need (323).

Over 40 percent (19) of States responding to thesurvey were defining shortage areas for physicianspecialties or for nonphysician health personnel.Eight respondents indicated that they were identify-ing shortage areas for all physician specialties, mostusing population-to-provider ratios specific to eachspecialty. Shortage designations for obstetricianswere the most common designation described (eight

States). Several States were either currently definingor were planning to define shortage areas for nurses.Other specialties for which States were designatingshortage areas include psychiatrists, pediatricians,family practitioners, internists, and general practi-tioners.



centralized and relatively uniform designation system, but they do so at the cost of being inflexible toState-specific priorities and needs. To fill in thegaps, some States have expanded on Federal desig-

nation criteria or created their own criteria to addressparticular problems. States that have developed theirown criteria generally apply more lenient or morespecific criteria in defining shortage areas.

In the OTA survey, State designation criteria werebeing used in almost one-half of the responding

When asked why States used their own criteriainstead of Federal HMSA or MUA designations,respondents said they viewed their State criteria as

a more accurate measure of need. Some respondentsstated that their State designation criteria wereaddressing areas of specialty shortage, were moresensitive to needs of frontier and other rural areas,were more lenient than HMSA criteria, or were moretimely.

Chapter 11--Identifying Underserved Populations .307

Table 11-16--Comparison of the Federal Index of Medical Underservice (IMU) and the Michigan Primary CareAssociation (MPCA) Modela

IMU weight MPCA weightFederal variable (percent ) (percent )

Percentage of persons below 100% of Federal poverty level . . . . . . . . . .25.1 20.7Five year infant mortality rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26.0 17.2Percentage of persons age 65 and over. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.2 17.2Primary care physician to population ratio. . . . . . . . . . . . . . . . . . . . . . . . . 28.7 13.8Percentage of persons Medicaid eligible . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA 20.7Unemployment rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA 10.4

100.0 100.0


aTheweights that appear in this table are those associated with least-needy extreme for each criterion (e.8. ,

the IMU weight of 25.1 for percentage of population below the Federal poverty level is associated with O% below poverty). (See 41 FR 45718-45723 for the complete weighting tables used for IMU computation. ) Lowerweights are associated with more critical need.

SOURCE: Michigan Primary Care Association, A Blueprint for PrimaryHealth Care: Conxnunities Building aHealthy Foundation,executive summary (Lansing, MI: November 1987).

Table 11-17--State Opinions on How Accurately Federal HMSAs and MUAs Reflect State HealthPersonnel Shortages, 1989a

Don’t know/ NoYes No no opinion Response

State has areas/populationsthat have health personnelshortages or are medically 38 (84%) 3 ( 7%) 3 ( 7x) 1 ( 2%)underserved but are notdesignated as HMSAs or MUAs

State has areas/populationsinappropriately designated 8 (18%) 29 (64%) 8 (18%) o ( o%)Federal HMSAs/MUAs

aBased on 45 States responding to OTA’S survey of shortage and underserved areas (see app. D).


Testifying to the limitationS of the Federal desig-

nation criteria, over four-fifths of respondents (38 of

45) believed that there were areas or populations in

their State that had health personnel shortages or

were medically underserved but were not designated

as Federal HMSAs or MUAS (table 11-17).Fourteen

States had designated such areas as State healthpersonnel shortage or medically underserved areas.Th t d d t b l t f th St t

lacked financial resources and staff to nominatethem for designation.

Seven States indicated that there were areas orpopulations in their States that were inappropriately

designated as Federal HMSAs or MUAs (table11-17). Several respondents speculated that inappro-priate designations existed due to the lack of review

f MUA d i ti



These areas tended to be rural parts of the State,areas with specialty shortages (i.e., shortages of obstetricians) and nonphysician shortages, and areaswhere the population-to-physician ratios were belowthe Federal HMSA cut-off. State designated popula-tions included Medicaid and indigent populations.When asked why these areas or populations were notfederally designated, respondents replied either thatthe areas lacked incentives to apply (e.g. limitedNHSC personnel availability) or that the State

of MUA designations.

States engaged in several other activities relatedto designating underserved areas (table 11-18).Forty percent of States (18 of 45) were delineatingprimary care service areas. The majority of States(32 of 45) were conducting special surveys of primary care providers to monitor shortage areas orunderserved areas; one-third of these were doing soas a part of HMSA designation and redesignation


Table 1 l-18—Shortage Area Designation Activity, by State, 1989

Has filed at least Has filed at Defines its ownone primary care least one MUA shortage areas for Delineates Conducts specialHMSA application applications certain health primary care surveys of primary

Statea

since 1985 since 1985 practitioners service areas care providers

AlabamaAlaskaArizonaArkansas

ColoradoDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisiana

Maine Maryland Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico

New York North CarolinaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtah

Vermont Virginia Washington West Virginia Wisconsin

xxxx

xxxxxxxxxxxx

xxxxxxxxx

xx

xxxxxxxxxxxx

xxxx

x ?

xx

xxxx

x

xxx

x

x

x

x?

x

x

xxxxx

x

xxxx

xxx

xx

x

xx

xx

xx

x

x

xxxx

xx

xxx

xx

x

xx

,

A x,

, xx

xxx

x

x

x

xx

x xx

x x

xxx

x xx

?

xx

xx

xxx

NOTE: X = yes; ? = don’t know or no response; blank=

th 45 St t th t d d t f

no.

h d d d i l d d



aonly the 45 States that responded to OTA’S survey of


activities. Some States reported surveying each

physician as a part of their relicensing procedure,and some States conducted annual surveys of CHCs,hospitals, or health departments. Other reasons fordoing surveys included monitoring obstetrician andnursing shortages and determining the number of private physicians accepting Medicaid patients. Onerespondent reported that their organization was no

shortage and underserved areas are included.

longer able to conduct surveys because of the lack of

staff time.

HMSAs AND MUAs: PROBLEMSAND ALTERNATIVES

There are two problems inherent in the identifica-tion and prioritization of health service shortage


areas. First, the terms “shortage” and “under-

service” are hard to define; second, the measure-ment of various indicators of shortage and under-service is constrained by the limited availability of accurate and current local data. Despite theseproblems, the Federal Government has pursued itsefforts to designate needy areas since the late 1960sand has relied on HMSA and MUA designations totarget Federal resources.

The distinction between HMSAs and MUA/Pshas not always been clear. The concept of medicalunderservice is broader than that of health man-power shortage, since the former relies on a numberof indicators of need, while the latter is primarilyconcerned with underservice attributable to lack of health personnel (339). Much of the confusionassociated with the purpose and validity of theFederal designations stems from the ambiguous

meanings of the terms ‘‘shortage’ and ‘‘medicalunderservice.

Shortage Area Designations

Federal policies to redistribute physicians throughthe NHSC program were based on the premise thatrelative physician shortages were associated withimpaired access to care. The NHSC program wasinitially tied to CHMSA designations in the early1970s to increase the number of providers in areaswith a relative undersupply.

The concept of shortage was broadened bychanges in the HMSA designation criteria estab-lished in 1978. Shortage was not only measured bythe relative supply of providers to an area, but alsoby taking into consideration socioeconomic barriers

to access and other indicators of need. The designa-tion of population groups as HMSAs was anadditional means of addressing the specific accessproblems that face certain populations. 20

Identifyingwhat the indicators of shortage should be anddeciding how they ought to be prioritized were

in the total hours worked, allocation of time to

different practice activities, and productivity (718).

In 1983, Berk and colleagues questioned whetherHMSA criteria result in a valid distinction betweenareas with adequate access to medical care and thosewith inadequate access (85). They evaluated fourmeasures of access to health care for populationsresiding in and out of HMSAs:

1. the likelihood of having any physician visits(in 1977),

2. the number of physician visits,3. travel time to usual source of medical care, and4. waiting time in the medical provider’s office or

place of practice.

The authors found that differences in access tohealth care were better explained by differences inincome, racial composition, and insurance coverage

than by differences in physician supply. Based onthese findings, they suggested that criteria bedeveloped that would more closely link factorslimiting access and utilization with low levels of physician supply, and they concluded that thephysician redistribution effort was “a relativelyinefficient mechanism for reducing inequities inaccess to care. ’

In 1983, the criteria used to designate HMSAswere evaluated as was required by law (Public Law97-35), and four alternative designation criteria wereevaluated:

1. 2.

3.

4.

the IMU,the Utilization Deficit Index (developed byresearchers at the National Center for HealthStatistics),the Deaths Averted Index (developed

searchers at the Urban Institute), andthe Use/Need Index (also developed

by re-

by re-searchers at the Urban Institute) (682).

While the HMSA criteria stress provider availa-bility, the IMU considers both availability and



deciding how they ought to be prioritized weremajor concerns in the development of HMSAcriteria.

One point of criticism of HMSAs has been theirreliance, despite these changes, on population-to-provider ratios. Critics have suggested that theseratios do not reflect differences between specialties

health status measures, and the other three indices allemphasize health status and health care utilization.The shortage area designations that would be

produced by the HMSA and alternative methodswere compared and contrasted. The alternativeswere assessed according to how well they rankedcounties in terms of need, access, health status,

20~$~e~~~ ~ been definedb~~ly as tie absen~ of geo~phic, financial, and capacity barriers that reduce a populations ability to reach (~vel

to), afford (pay for), and obtain in a timely manner health services that are wanted or desired (682).


utilization, insufficient capacity, and health person-nel availability.

Although different groups of counties were identi-fied by the different alternatives, all methods identi-fied a core group of the same counties. Thesecounties were predominantly poor, rural counties inthe South (682). The HMSA criteria appeared to bethe most effective in ranking counties by relativeavailability of health personnel—not surprising,

since the other methods did not necessarily empha-size personnel availability.

In this 1983 evaluation, HRSA also evaluated thecriteria used to determine “degree-of-shortage’groupings among HMSAs. The agency found thatthe priority groupings: 1) gave undue importance todifferences in population-to-practitioner ratios andcertain measures of unmet need; 2) did not consider

the size of affected populations; and 3) did not takeinto account unmet demand or area attractiveness(682). Despite some efforts to develop better degree-of-shortage criteria, the original priority groupingscontinue to play a role in the allocation of NHSCpersonnel.

Undeserved Area Designations

The lack of a generally accepted definition of medical underservice has generated considerablecriticism. Wysong, for example, criticized the IMUfor its failure to define medical underservice di-rectly, noting that the IMU simply attempted topredict the assessments experts would make if theyactually visited sites (742). Critics contend that thelack of any empirically verifiable concept makes theIMU difficult to interpret and also difficult to defend

as a basis for policy formation (682).Several studies examined how well the IMU

identifies residents with poor access to health care.Kleinman and Wilson used data from the 1973 and1974 Health Interview Surveys to determine whetherresidents of rural areas satisfying MUA require-

that underservice should be defined as deviationsfrom those standards.

Kushman evaluated the IMU as a predictor of theability to obtain physician services using CaliforniaMedicaid claims (329). He found that the IMUexplained only one-fifth of the variation in thenumber of claims across counties. When nonwhiteand urban populations were considered as independ-ent variables in addition to the IMU, the regression

equation explained nearly one-half of the variationin claims. Kushman concluded that the IMU did notadequately reflect barriers to physician servicesfaced by nonwhite and rural persons and thatprograms using the IMU run the risk of misallo-cating resources toward whites and urban dwellers.

Other noted limitations of the IMU include theIMU’s insensitivity to consumers’ perceptions of health care needs and the way individuals select andutilize health services (330), the absence of a cleardefinition of ‘rational service area,’ and the lack of consideration of needs and available services incontiguous areas (339).

Criticisms that current measures of underservicemay not be adequately identifying areas in greatestneed prompted a 1987 study of the usefulness of health status, as measured by sentinel health events,

to identify underserved areas (55). Sentinel healthevents are medical conditions that, by virtue of theirpresence or prevalence in a population, indicate alack of access to acceptable-quality preventive andother primary health care. Examples of sentinelhealth events include dehydration in infants; mea-sles, mumps, or polio in children; and advancedbreast cancer or invasive cervical cancer in adultwomen. Identifying areas and populations that are

potentially underserved involves calculating therelative rate of sentinel events among different areasor populations. The study found that sentinel healthevents were effective in identifying underservedurban areas, but results were inconclusive in ruralareas. At present, the most promising use of sentinel



residents of rural areas satisfying MUA requirements had poorer access to medical care than others(321). No difference was found between MUAs and‘‘adequately served” areas in volume of physicianvisits per resident, and only a small difference wasfound in the proportion of residents with one or morevisits per year. MUA residents used some preventiveservices less and nonsurgical hospitalization more.The authors concluded that there was a need forspecific objective standards of appropriate care and

heath events is as a supplement to existing methods,to identify certain populations groups and subgroupsthat may have impaired access (55).

SUMMARY OF FINDINGS

While there are no definitive criteria that definewhat constitutes the “adequate” supply of healthcare in given area, the Federal Government hasdeveloped measures of “shortage” and “medical


underservice" that attempt to identify areas andpopulations with a relative lack of health care.

As measured by personnel shortage, rural healthneeds remain high. Contrary to predictions, anddespite overall increases in physician supply, the

number of designated primary care HMSAs actually increased 30 percent between 1982 and 1988. In 1988, 29 percent of the U.S. rural population(16.5 million people) lived in designated primary

care HMSAs. States continue to request new short-age designations. Where demand for designationshas declined, States report that it has been due in partto the decreased availability of incentives linked tothese designations (e.g., NHSC personnel and newCHC funds) and the lack of funds to engage indesignation activity.

In general, States regard HMSA criteria as rele-vant and workable. Points of dissatisfaction includethe cut-off point of 3,500:1 for the population-to-primary care physician ratio (which is often regardedas being too high), the lack of adequate considera-tion of the productivity and the actual availability of physicians, and the often long processing timeassociated with designation. The use of HMSApriority groupings as a means of allocating resourceshas also been challenged. The prioritization processis not as public as it could be. The criteria used todetermine the HPOL list, on which NHSC personnelplacements are based, have never been published.

Unlike HMSAs, MUA/P designations attempt tomeasure health underservice by considering primar-ily measures of health service demand rather thansupply. Although the MUA criteria may well be a

better measure of impaired access than the HMSA criteria, the Federal identification and administra-

tion of MUA/Ps has some major problems. BecauseMUAs have not undergone a regular review since1981, they cannot be viewed as an accurate indica-tion of the current level of medical underservice,either on an individual area or national basis. Otherpotential problems associated with MUA designa-

tions concern the use of IMU weights and cut-off point that have not been reexamined since 1976, theambiguous status of MUA designations during thepast decade, and decreases in the incentives forStates to apply for MUA designation.

There appear to be a substantial number of areas and populations that have health personnel shortages or are medically underserved but are not designated as Federal HMSAs or MUAs. In 1986,there were 95 nonmetro counties that qualified asHMSAs based on whole-county population-to-physician ratios

21but were not designated as HMSAs

(511). It is also possible that a number of subcountyareas may have also qualified but not applied forHMSA designation. Four-fifths of respondents toOTA’s survey (38 States) believed that there wereareas or populations in their State that had healthpersonnel shortages or were medically underservedbut were not designated as Federal HMSAs orMUAs.

Some States have engaged in activities to help fillin the gaps where Federal designations do notadequately address special State problems. At least22 States use their own designation criteria either

alone or in conjunction with HMSA or MUA criteria, to implement State health personnel distri-

bution programs. Examples of other State designation-related activities include defining shortage areas forphysician specialties or for nonphysician health careproviders, defining primary care service areas, andusing State surveys of primary care providers tomonitor health personnel shortages and medicallyunderserved areas.

State criteria are generally more specific or more

lenient than Federal criteria, and they are believed bythe States to be more sensitive to the needs of ruraland frontier areas, to specialty shortage areas (e.g.,obstetricians), and to needs that must be met quickly.State shortages of resources and staff, however, havelimited designation activities.



zlmclud~ doctors of medicine Ody.

20-810 0 - 90 - 11 QL3

Chapter 12

Problems in the Recruitment

and Retention of

Rural Health Personnel



CONTENTS Page

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

FACTORS AFFECTING PHYSICIAN SPECIALTY CHOICE ...... + . . . . . . . . . . . . . . . 315FACTORS INFLUENCING WILLINGNESS OF HEALTH PROFESSIONALS

TO PRACTICE IN RURAL AREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .316

Personal Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .316

Professional Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .318

Economic Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .323

Concerns of Allied Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

Factors Affecting Physician Specialty Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331Factors Affecting Location Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

Figures Figure Page

12-1. Average Number of Hours Worked and Average Number of Patients Seenby Physicians, by Specialty and Location, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

12-2. Average Liability Insurance Premium as a Percent of Average Gross Income of Self-Employed Physicians in Selected Specialties, 1982-88 . . . . . . . . . . . . . . . . . . . . 329

Tables

Table Page12-1. Number of Hours Worked Per Week and Number of Weeks Worked Per Year

by Registered Nurses, by County Population Size, 1988 . . . . . . . . . . . . . . . . . . . . . . . 31812-2. Coverage and Direct Payment for Services of Midlevel Practitioners . . . . . . . . . . . 32112-3. Registered Nurses Employed in Nursing: Percent of Time Spent in Various

Professional Activities and Percent Enrolled in Advanced Nurse EducationPrograms, by County Population Size, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324

12-4. Income of U.S. Physicians (as a Percentage of Average Physician Income)by Specialty and Practice Location, 1977 through 1986 . . . . . . . . . . . . . . . . . . . . . . . . 325

12-5. Average Annual Salary Range of Physician Assistants by Community Size,1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325

12-6. Average Annual Salary of Registered Nurses, by County Population Size,1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326

12-7. Average Prevailing Charges for Selected Procedures by Geographic Location,Actual and Adjusted for Differences in Practice Costs, 1987 . . . . . . . . . . . . . . . . . . . 327

12 8 M di id M i P t d M di M i All bl Ch f



12-8. Medicaid Maximum Payments and Medicare Maximum Allowable Charges forSelected Services, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328

Chapter 12

Problems in the Recruitment and Retention

of Rural Health Personnel

INTRODUCTION

The future supply of rural health professionals isdependent on a sufficient supply of professionalsappropriately trained for rural practice, and theirwillingness to locate and remain in rural areas.Factors affecting health professionals’ specialty andlocation choice fall into three general categories:

1.

2.

3.

personal factors (e.g., work hours, socialopportunities, spouse employment, and school-ing for children);

professional factors (e.g., opportunities forprofessional consultation, community and pro-fessional acceptance, and opportunities forcareer advancement); and

financial factors (e.g., educational debts, in-come, and practice costs).

Although recent attention has focused on eco-nomic disincentives to rural practice, noneconomicissues also play a critical role in recruitment andretention of rural health professionals. For someprofessionals, the perceived amenities of rural prac-tice outweigh its disadvantages. For others, the mostattractive salaries would not compensate for theperceived drawbacks of rural areas. This chapterpresents an overview of factors affecting healthprofessionals’ specialty and location choices. It alsodiscusses more specifically some of the key prob-lems in recruitment and retention of rural healthprofessionals. The chapter is largely concerned withphysicians because of the relative abundance of studies and data on physician recruitment andretention. Many physician recruitment and retentionissues, however, apply generically to other healthprofessionals as well.

Critics assert that the current medical educationsystem encourages specialty and academic practiceand discourages students from pursuing primarycare (206,506,556,604,608). It is commonly be-

lieved that medical school graduates are increas-ingly electing nonprimary care fields because theseare more profitable. Although earning potential isnot frequently mentioned by medical students as amotivator of specialty choice (58,61), a recentanalysis suggests that it may be a factor (180). In1987, the median net income of office-based familypractitioners (FPs) and pediatricians was roughlyone-half that of office-based ophthalmologists, diag-

nostic radiologists, orthopedic surgeons, and anes-thesiologists. Net specialty income correlated posi-tively with both the number of applications peravailable residency position and the percentage of available residency positions filled for variousspecialties (180).

Other factors may also be contributing to thecurrent trend away from primary care specialties,including:

q

q

q

The

the perception that primary care practice is lessprestigious or less intellectually challengingthan other specialties (206,326),

the belief that primary care residencies andprimary care practice are more demanding andrequire longer hours than other specialties(61,312), and

the lack of positive role models in the primarycare specialties (206,506,556,604,608).

three factors most frequently mentioned by1989 medical college seniors as the most importantdeterminant of their specialty choice were intellec-tual content of the specialty (30 percent of gradu-ates) type of patients encountered (16 percent) and



FACTORS AFFECTING

PHYSICIAN SPECIALTY CHOICEBecause rural areas rely so heavily on primary

care physicians (see ch. 10), the recruitment of physicians into primary care is the first step in ruralphysician recruitment. The recruitment process thusbegins in the earliest stages of medical education.

ates), type of patients encountered (16 percent), andphysician role models in the specialty (12 percent)(61). Very few seniors indicated that their choice

was based on the ‘‘prestige’ of that specialty withinthe medical profession (60,61).

Over two-thirds of 1989 medical school seniorsindicated that they had determined their currentspecialty preference during the third or fourth yearof medical school (61). A substantial proportion (13

–315-


percent) indicated that they had chosen a specialtybefore entering medical school (61). About two-thirds of 1988 and 1989 seniors who indicated aspecialty choice had changed their preference duringmedical school. In both years, those students hadmost frequently rejected the specialties of familypractice, internal medicine, general surgery, andobstetrics/gynecology (60,61). The three reasonsmost commonly given for the decision against a

previously considered specialty were excessive de-mands on time and effort, inconsistency withstudent’s personality, and negative clerkship experi-ences (60,61).

A study of 1983 medical school graduates foundthat receipt of a Federal scholarship was the mostpowerful predictor of selection of a primary carespecialty (168). This same study found that women

and married students were more likely than others toenter a primary care field, and that high levels of student indebtedness were somewhat associatedwith preferences for nonprimary care specialties andintent to enter academic, research, or administrativepositions (168).

Some States and regions send a relatively high

proportion of their medical graduates into primarycare. A study of 1983 medical school graduates(544) found that the percentage of graduates enteringfamily practice residencies was highest in the Pacific(17.5 percent) and Mountain (16.1 percent) regions.Regions with the lowest percentages were NewEngland (7.1 percent) and the Middle Atlantic (8.1percent). In 7 States, at least 20 percent of graduatesentered family practice residencies;

lin 10 States and

the District of Columbia, fewer than 10 percent didso.

2New York, which continues to have the highest

number of medical graduates per year of any State,sent only 3.2 percent of its graduates into familypractice residencies in 1988 (744). For individualmedical schools, percentages in 1983 ranged from0 8 t t C ll U i it i N Y k t

FACTORS INFLUENCINGWILLINGNESS OF HEALTHPROFESSIONALS TO PRACTICE

IN RURAL AREAS

In the overwhelming majority of studies reviewedby OTA, personal characteristics and professionalconcerns were found to be of greater influence thanfinancial factors on the location choices of physi-cians. The concerns of rural physicians apparentlyhave not changed appreciably over the years. Astudy of physicians practicing in rural areas in 1967(90) found areas of concern similar to those identi-fied by more recent surveys. Most physicianspracticing in rural areas are satisfied with their jobs(239,405,461), although one study found evenhigher satisfaction rates among urban physicians(239).

Personal Factors

Preference for rural or urban practice locationseems to depend more on a personal preference forrural or urban living than on specific characteristicsof rural or urban settings (239). Rural upbringing isa major influence on the decision for rural practice(71,90,142,144,165,239,280,313,507,592,719), as is

the preference for a rural lifestyle (239,405,507).From 1978 to 1986, however, the number of enrolledmedical students from rural areas decreased by 31percent while the total number of enrolled studentsremained essentially the same (500). This decreasewas primarily due to a drop in the number of applicants from these areas (500).

Lower socioeconomic background (124,238), ex-perience in the National Health Service Corps (333),

and participation in a loan forgiveness program tiedto service obligation (372) are also associated withchoice of a rural practice location. Minority physi-cians are more likely to practice in areas with largeminority populations, suggesting that the recruit-ment of minority medical students may help allevi-ate the critical medical manpower shortages in some



0.8 percent at Cornell University in New York to34.2 and 38.5 percent, respectively, for the Univer-sity of North Dakota and Oral Roberts University inOklahoma (544). In general, private medical schoolgraduates are less likely than public school gradu-ates to choose a primary care specialty (168).

ate the critical medical manpower shortages in someof these areas (507,669).

The locations of both undergraduate and graduatemedical education are also important determinantsof physician practice location. An analysis of 1982data found that 39 percent of all physicians were

IThese Stites were Mississippi, Colorado, New Hampshire, Washington 1owa, N o * DAoti% a nd ~~~s (544).

~ e s e States were New York Nevad~ Connecticut, Massachusetts, Rhode Island, Hawaii, Orego~ Georgia North Carolina, and Missouri (544).

Chapter 12--Problems in the Recruitment and Retention of Rural Health Personnel q 317

Figure 12-1—Average Number of Hours Worked and Average Number of Patients Seen by Physicians,by Specialty and Location, 19888

A. Mean number of hours spent per week in

professional activities, 1988

70.6

62.2

—All physicians

b

General/family practice Obstetrics/gynecology

= Al l n o n m e t r o = Metro c1,000,OOO n Metro >1 ,000 ,000

C. Mean number of total patient visits per week, 1988170.4

153.3

B. Mean number of hours spent per week in direct

patient care activities, 1988

61.2

54

47.8

54.7 ,9

All physicianC General/family practice Obstetrics/gynecology

= All nonmetro = Metro ~1,000,000 D Metro >1 ,000 ,OOO

D. Mean number of office visits per week, 1988

127.5155.1

102.8

113.2

All physicians 0 General/family practice Obstetrics/gynecology

= All nonmetro = Metro <1,000,000 m Metro >1,000,000

All physicians c General/family practice Obstetrics/gynecology

= All nonmetro = Metro c1,000,OOO m Metro >1,000,000

ahes not i~lude Osteopathic physicians, Federal physicians, residents, and physicians not in patient care.bln~~es ptlys~ians in all specialties not listed.

CEXCIUdSS physicians in radiology, psychiatry, anesthesiology, and pathology.

SOURCE: Office of Technology Assessment, 1990. Data from M.L. Gonzalez and D.W. Emmons, Soa”oeconomh ChaactetiSt& ofh-fedicd Practice 1989 (Chicago, IL: American Medical Association, 1989).

practicing in the same State where they receivedtheir undergraduate training, and 51 percent werepracticing in the same State where they receivedtheir graduate training (112). Graduates of public orless prestigious medical schools and training pro-grams were more likely than other graduates to

leisure time has been cited as a source of jobdissatisfaction among rural physicians (461). Physi-cians in rural areas work more hours and see morepatients per week than do their urban counterparts(figure 12-1) (218). For solo practitioners in isolatedrural communities, hours of coverage may be



g y gremain in the State of their training. General andfamily practitioners (G/FPs) and obstetrician/

gynecologists (OB/GYNs) were more likely thanother specialists to practice in the State where theyobtained their medical degree or specialty training(112).

Adequate personal time plays a significant role inphysician location decisions (405), and lack of

, g ycontinuous, with little or no opportunity for respite,vacation, or continuing education.

Available data on work hours of registered nurses(RNs) reveal little difference between rural andurban areas for these professionals (table 12-1)(317).

Another area of concern for rural health profes-sionals is the availability of employment opportuni-


Table 12-1—Number of Hours Worked Per Week and Number of Weeks Worked Per Year by Registered Nurses,by County Population Size, 1988

Mean number of weeks Mean number of hoursCounty population size

aworked per year worked per week

All U.S. counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49.9 34.5

More than 50,000 residents . . . . . . . . . . . . . . . . . . . . 49.9 34.550,000 or fewer residents. . . . . . . . . . . . . . . . . . . . . 49.9 34.7

25,001 to 50,000 residents. . . . . . . . . . . . . . . . . . 50.1 34.910,001 to 25,000 residents. . . . . . . . . . . . . . . . . . 49.6 34.5

10,000 or fewer residents. . . . . . . . . . . . . . . . . . . 49.7 34.4

acounty population size does not necessarily reflect metro or no~etro status.bN@er of week9 and hours in principal Position.

SOURCE: D.A. Kindig, University of Wisconsin, Madison, WI, and H. Movassaghi, Ithaca College, Ithaca, Ny,

unpublished analysis of data from the 1988 National Sample Survey of Registered Nurses (provided bythe Division of Nursing, Bureau of Health Professions) conducted under contract with the Universityof North Dakota Rural Health Research Center, Grand Forks, ND, 1989.

ties for their spouses. In general, small rural commu-

nities provide limited professional opportunities,and local communities often have to “recruit thespouse’’ when trying to attract a provider to the area.Forty-four percent of 1989 senior allopathic medicalstudents were either married or engaged to bemarried. Of these students’ spouses or spouses-to-be, 18 percent were also physicians, 59 percentwere in other professional occupations, and 83percent intended to work after their spouses had

completed their medical education (61).

The availability of quality education for childrenand the availability of social and cultural activitiesalso have been cited as possible disincentives torural practice, although urban as well as ruralphysicians mention the lack of these amenities asdisadvantages to their current practice location(239).

Professional Factors

Health professionals may be dissuaded fromchoosing a rural practice location due to either aperceived or an actual lack of professional opportu-nities and benefits. Unlike their urban counterparts,many rural health professionals do not have easy

vancement, ability to meet continuing education

requirements for recertification, and statutory, regu-latory, and reimbursement restrictions on profes-sional autonomy and scope of practice. This sectiondescribes the barriers that some of these concernscreate for health professionals in rural environments.

Physician Concerns

Ability to keep up with advances in medicine andavailability of adequate support facilities can be keyfactors in physician location decisions (405), butthese amenities tend to represent to a lesser degreein rural than in urban areas. For physicians who arealready practicing in rural areas, factors associatedwith job satisfaction include the quality of physician-patient relationships, availability of good facilities,technical quality of medicine, practice autonomy(239), diversity of patients, and personal gratifica-

tion derived from patient care (461). Factors associ-ated with job dissatisfaction include heavy workload/ long hours, lack of professional and educationalresources or distance from other health facilities(239,405,461), bureaucratic interference (239), andmeeting expectations of high-quality care (461). Theperceived or actual lack of professional resources inrural areas may discourage some physicians from



y p yaccess to professional colleagues, consultations andsecond opinions, medical libraries, or continuing

education. Moreover, rural primary care physiciansmay infrequently treat many conditions, and ruraltechnical personnel may find it difficult to maintaincompetence in skills they rarely practice. Otherprofessional concerns that may influence the loca-tion choices of health professionals-particularlynonphysicians—include opportunities for career ad-

rural areas may discourage some physicians fromlocating there.

Preference for Group or Salaried Practice—Trends toward group and salaried practice haveserious implications for smaller rural communities.Young physicians today tend to prefer practicearrangements that guarantee them a fixed incomeand other desired benefits, such as regular hours,vacation time, and a close professional community

Chapter 12-Problems in the Recruitment and Retention of Rural Health Personnel q 319

(378). A recent survey of 300 medical residents(327) found that 51 percent preferred group practice,30 percent preferred employment in health mainte-nance organizations (HMOs), and only 1 percentpreferred partnerships with established physicians.HMOs, however, are rarely located in rural areas(see ch. 5), and group practices may have troublegenerating sufficient patient volume in very smallcommunities.

American Medical Association (AMA) data con-firm that young physicians are increasingly choos-ing salaried over private practice, but they alsosuggest that many of these physicians change fromsalaried to private practice before the fifth or sixthyear of their career (218). It is not known whetherphysicians tend to remain in the same community ormove to larger or smaller communities when they

leave salaried practice. Increasing educational debts(see “economic factors” below) may be one reasonbehind the trend towards salaried practice, but thishas not been shown empirically.

Impact of Hospital Closures on Physician Supply--The large number of rural hospital closures in recentyears raises concerns about effects on the availabil-ity of rural office-based physicians. The presence of a hospital has been found to play a significant role

in the initial location decisions of physician special-ists but a lesser role for primary care physicians(90,241,576). Less is known about the effect of hospital closure on local physician supply. A recentstudy found no conclusive evidence that ruralhospital closure reduced the availability of localoffice-based generalist or specialist physicians dur-ing the periods 1970-80 and 1980-85

3(273). A

recent Minnesota survey examined the issue pro-spectively. When asked whether the closure of theirlocal hospital would affect their decision of wheretopractice, only 21 percent of rural physicians repliedthat it would not affect their decision, compared with64 percent of physicians in the Twin Cities metroarea and 50 percent of physicians in the Duluth andRochester metro areas (173). Individual cases where

Midlevel Practitioner ConcernsFactors influencing the location decisions of

midlevel practitioners (MLPs)4have not been stud-

ied as extensively as those influencing physicians,but isolated studies indicate that professional con-cerns play a key role. In a recent survey of graduatesfrom a certificate-level nurse practitioner (NP)training program in eastern North Carolina thatplaces most of its graduates in rural practice, the fourprimary incentives for choosing a particular sitewere professional autonomy, good salary benefits,adequate medical backup, and educational opportu-nities (337). Many MLPs are required to participatein accredited continuing education programs inorder to maintain licensure, but those practicing inrural areas may have difficulty accessing accreditedprograms. Federal and State restrictions on MLPs’scope of practice and on reimbursement for theirservices are key concerns for MLPs and are likely toinfluence their location decisions.

State Restrictions on Scope of MLP Services—The quality of care delivered by MLPs within theirareas of competence has been described as at leastequal to that provided by physicians (617), and someStates allow certain MLPs to provide these servicesin independent settings. Other States, however,

sharply limit the types of services MLPs mayprovide and the conditions under which they may beprovided. Such diverse policies may influence thelocation decisions of MLPs.

The practice of NPs is governed by State nursepractice acts. States always require collaborationwith or supervision by a physician, but they vary intheir specific terms and conditions. NPs can and do

practice without direct physician supervision in allStates.

5In 1990, 32 States allowed some form of

prescriptive privileges for NPs, but only three Statesallowed NPs to prescribe medication without anycosigning or approval by a physician (603).

The professional autonomy of physician assis-tants (PAs) is much more limited A fundamental



Rochester metro areas (173). Individual cases wherehospital closure has endangered access to physicianservices have been reported (267).

tants (PAs) is much more limited. A fundamentaldifference is that PA practice is defined under Statemedical practice acts. Forty-nine States

6and the

s~e au~ornoted two possible limitations in the study method that may have affected the results: 1) the measurement of hospital 10 W ma y ~ve ~ntoo imprecise, and 2) the availability of other hospital facilities nearby was not taken into account.

41ncludes nurse practitioners (NPs), physician assistants (PAs), certified nurse-midwives (CNMs), and c d f k d registerd nurse anes~etists

(CRNAS) (see ch. 10).SRestrictive fitewm~tion of nurse practice acts in one or two States may limit the SCOPC of NT practice (603).

me exception is New Jersey, where PAs are not legally recognized health professionals and are permitted to work only in Federal facilities (16).


District of Columbia allow PAs to provide medicalservices under physician supervision, but the natureand extent of the supervision vary. All of these Statesexcept Colorado permit some conditions underwhich PAs can practice without a physician physi-cally present in the room. Fewer States allow PAs topractice with off-site physician supervision.

7As of

March 1990,24 States and the District of Columbiaallowed PAs to prescribe some medications (192).

8

Restrictions such as these prevent the utilization of PAs in rural satellite or remote practice settings.

Institutional and medical restrictions on scope of practice, liability coverage costs and availability,and stringent educational requirements present bar-riers to CNM practice (24,617). These barriers maybe of particular concern to rural CNMs who practicein remote areas and therefore require a greater degree

of autonomy. As of 1989, 5 States required abachelor’s or master’s degree in nursing for nurse-midwifery practice, and 19 States required continu-ing education units for either RN or nurse-midwifelicense renewal (25). All nurse-midwives certified

by the American College of Nurse-Midwives arerequired to complete continuing education units forcertification renewal (191 ). Some rural CNMs havedifficulty fulfilling continuing education require-

ments due to lack of recognized continuing educa-tion programs in some States and areas. TheseCNMs must travel to regional workshops to receivetraining, often at their own expense (191).

As with NPs and PAs, restrictive State (nurse)practice acts limit autonomous CNM practice insome States (191). Thirty-one States did not grantprescriptive privileges to CNMs in 1989, althoughsome are now considering changes in their policies.

9

Moreover, some State hospital licensing laws pre-vent hospitals from allowing CNMs admittingprivileges (191).

Reimbursement Disincentives for MLPs and Their Employers—A major barrier to the utilizationof MLPs is the limited coverage for their services

d M di M di id d th thi d t

matters of economic concern for their employers andprofessional concern for the MLPs themselves, andthey may play a role in MLPs’ location decisions.

Table 12-2 summarizes coverage and direct pay-ment for the services of MLPs under Medicare,Medicaid, and other third-party payers. MLPs re-ceive third-party reimbursement for their servicesdirectly or indirectly (through their employers or

supervising physicians). Reimbursement for MLPsunder Medicare and Medicaid is limited to certainsettings and conditions, and reimbursement by otherthird-party payers varies dramatically by State andby insurance plan.

Medicare—Although reimbursement of MLPsunder Medicare Part B has expanded over the pasttwo decades, it is still subject to many restrictionsand, with few exceptions, payments are made to the

employer rather than directly to the MLP. Legisla-tion passed in 1982 (Public Law 97-248) authorizedindirect Medicare reimbursement for PA and NPservices delivered without direct physician supervi-sion within HMO settings. Subsequent legislationauthorized indirect Medicare reimbursement for PAservices delivered under physician supervision inhospitals and nursing homes, for assistance duringsurgery, and for PA services delivered in ruralHealth Manpower Shortage Areas (HMSAs) (PublicLaws 99-509, 100-203). Legislation in 1989 (PublicLaw 101-239) authorized indirect Medicare reim-bursement for the services of NPs in skilled nursingfacilities. Recent reports indicate an increased de-mand for PAs in certain hospital settings (see ch.10). Medicare reimbursement for NPs and PAs inHMO settings may limit the supply of these practi-tioners in rural areas, since it increases the demandfor NPs and PAs in HMOs’ predominantly urbansettings. Anecdotal reports indicate increased de-mand for PAs in some rural clinics following the1987 amendments (192).

NPs, PAs, and CNMs in certified rural healthclinics (RHCs) obtain indirect cost-based reimburse-

t d M di f th i i10

Alth h



under Medicare, Medicaid, and other third-partyplans (617). Reimbursement issues for MLPs are

ment under Medicare for their services.10

AlthoughRHC legislation was passed in 1977 (Public Law

7&cor&g to the America Acaday of physician Assistants, PA practice in satellite or remote settings would be diffkndt if not impossible in atleast five States due to language in or interpretation of medical practice acts. These States are Colorado, Louisiana, Mississippi, New Jersey, and SouthCarolina (192).

~~ additio~ six Stites wtich do not WOW PAs to prescribe drugs do allow them to dispense ce@ PrMcriPtiOn ~gs (192).

?in 19 States and the District of Columbia, prescriptive privileges are authorized, but the scope of the authority varies greatly. In two States, CNMprescriptive authority has been challenged by the State Attorneys General (191).

IoSemic= of clinical psychologists and social workers furnished in RHCS are also reimbursed by Medicine.

Table 12-2—Coverage and Direct Payment for Services of Midlevel Practitioners

a

Nurse Physic i an Certified Certified Registered

Practitioners (NPs) Assistants (PAs) Nurse-Midwives (CNMs) Nurse Anesthetists (CRNAs)-

Third-party payer Coverage Direct payment Coverage Direct payment Coverage Direct payment Coverage Direct payment

Medicare:

Part A

Part Bb

HMOse

State Medicaid programsf

Medicare and Medicaid:

Rural Health Clinicsh

Private insurance

NoSome

c

Yes

Some

States

Yes

Some

States

NoNoNA

A few

Statesg

NoSome

States

No No NoSome

dNo Yes

Yes NA NA

Some No Almost all

States States States

Yes No Yes

No No Some

States

NoYes

NA

Almost all

States

NoSome

States

NoYes

Yes

Most

States

NA

Some

States

NoYes

NA

At least 20States

NA

At least 13

States


a“Coverage” means reimbursement is provided to the employer. “Direct payment” means that reimbursement is made directly to the

practitioner. “Services” means services that are typically and characteristically provided by physicians. Most payment for midlevel

practitioner services, whether direct or indirect, is at levels lower than a physician would receive for comparable services.b

Direct reimbursement for CRNA services was mandated In 1986. Direct reimbursement for CNM services delivered without direct physician

supervision but in accordance with State practice acts was mandated in 1987.crndlrect part B rel~ursement for the services of lips in skilled nursing faClllties was mandated in 1989.

%edicare reimbursement for PA services delivered under physician supervision in hospitals, nursing homes, and as assistants during

surgery was mandated in 1986. Medicare reimbursement for PA services furnished in rural primary care Health Manpower Shortage Areas

was mandated in 1987, Payment is made to the supervising physician or to the employer.‘prepaid Paments t. certain Health Maintenance organizations (HMOs) for NP and pA services were mandated in 1982.

fstates have the option of reimbursing for Np, PA, and CRNA services but are required to reimburse for the services of CNMS delivered

without direct physician supervision.g1989 legislation required all States to reimburse directly for the services of pediatric and family nurse practitioners in all

settings. The new policy is scheduled to take effect in June 1990.

klinics certified under Public Law 95-210 (see ch. 3). Reimbursement is indirect and is cost-based rather than prospective.ilndlcates whether states have laws that, reqlre or ~ermlt Private insurers to cover or directly reimburse for the services Of NPs, pAs,

CNMS, and CRNAS.





95-210), implementation among States has beenhighly uneven. Over 2,000 counties in all 50 Statesqualify for RHCs,

11yet in 1989 only 470 RHCs were

certified in 37 States (table 5-15). In 8 States, eachof which had more than 40 qualifying counties, therewere no RHCs at all (table 5-15). Under the law,MLPs can work without direct physician supervi-sion only within the proscriptions of State nurse andmedical practice acts. Reasons for the lack of RHCs

in some States may include restrictions on MLPscope of practice and resistance from the medicalprofession (516) or simply lack of awareness of theprogram. The RHC certification process can belengthy and can cause substantial financial difficultyfor some clinics (see ch. 5). The ability of clinics inrural HMSAs to obtain fee-for-service reimburse-ment from Medicare for PA services (see above)while seeking certification may ease the financial

burden on these clinics, but clinics still cannot obtainsuch reimbursement for the services of NPs (192).(See chs. 3 and 5 for further discussion of the RuralHealth Clinics Act and barriers to its implementa-tion.)

Unlike most other MLPs, certified registerednurse anesthetists (CRNAs) may bill Medicaredirectly for their services. Direct Medicare reim-

bursement for CRNAs was mandated in 1986(public Law 99-509). The American Association of Nurse Anesthetists, however, believes that reim-bursement is too low (23).

Medicaid—Legislation in 1980 (Public Law 96-499) required that States reimburse for CNM serv-ices under Medicaid, regardless of whether theseservices are provided under direct physician supervi-sion. Legislation in 1985 (Public Law 99-272)further directed that CNM-operated birthing centersdo not have to be administered by physicians inorder to qualify for Medicaid reimbursement. Legisla-tion in 1989 (Public Law 101-239) required States toprovide direct reimbursement under Medicaid forthe services of pediatric and family NPs, regardless

indirect cost-based reimbursement under Medicaid(see above).

Excepting the previous provisions, States are notrequired to reimburse PAs and NPs under Medicaid,but at least one-half of States exercise their option todo so to some extent (418). The method of reim-bursement in these States varies. Several States limitdirect reimbursement to NPs to certain procedures,such as obstetrics. At least 20 States directlyreimburse CRNAs under Medicaid (601).

12Most

other States also reimburse CRNAs under Medicaid,but the method of reimbursement may be indirect(e.g., through a hospital) (601).

Private Insurance-Private insurance coverageof MLP services varies both by individual insuranceplan and by State. In some States, legislation eitherrequires or allows third-party payers to reimburse for

MLP services (table 12-2), but some plans reimbursein States where there is no mandate. Twenty-sixStates either allow or mandate direct private third-party reimbursement for NP services, and 7 othersallow or mandate direct reimbursement for certifiedpsychiatric NPs (603). NPs have succeeded inobtaining direct reimbursement from some privateplans. As of 1989, 20 States had mandated privateinsurance reimbursement for CNM services, but the

method of reimbursement varies (25). Most privatethird-party payers reimburse either directly or indi-rectly for CRNA services, and at least 13 Statesrequire direct reimbursement for their services(601).

Nurse Concerns

Rural nurses cite lack of opportunities for careeradvancement, low salaries, and increased responsi-bility for non-nursing tasks as sources of jobdissatisfaction. The same factors have been associ-ated with recent declines in applicants to nursingprograms (698). Lack of professional autonomy(e.g., inability to influence their own practiceenvironment and characteristics) is regarded bymany as one of the key factors affecting nurse



of whether the NP is under the supervision of orassociated with a physician or other health careprovider (effective July 1, 1990). PAs, NPs, andCNMs in designated rural health clinics also receive

retention and job satisfaction (232,262 #10,370,469,593,717,733,). A study of nurses in rural Geor-gia hospitals found personal characteristics—including age, education, salary, marital status, and

ll~s is ~und~es~tionof th e ~M numb~of qw@ing counties, since it only includes qualifying nonmerro counties. Under Public ~w95-*10,clinics innonurbanized areas of metro counties can also qualify if the areas meet the criteria fordesignationas aMedicallyUnderserved Area or a primarycare HMSA (see ch. 11).

12’T’his fi~e k based on a wey conducted several years ago, and more States may now be m~msing tiecflY (~~).


number of dependents-to be relatively unimportantpredictors of rural hospital nurses’ job satisfaction(232). The influence of these factors on those nurses’initial location decisions, however, was not studied.

Nurses in remote settings maybe less likely thanurban nurses to have opportunities for career ad-vancement (e.g., upgrading from a licensed practical/ vocational nurse to an RN or from an RN to an

advanced nursing position) due to poorer access toeducation programs and less flexible work sched-ules. Nurses in more populated counties are morelikely than those in less populated counties to beenrolled in nursing-related educational programs(table 12-3) (317). Rural RNs also spend more timein supervisory and administrative activities than dotheir urban counterparts (table 12-3) (317). Whetherthis difference is looked on favorably by RNs is not

known, but it does diminish the amount of time thesenurses spend in direct patient care (table 12-3).

RNs in less populated counties are less likely thanothers to have bachelors’ degrees (table 10-43)(317). The availability of upgrade programs for RNswithout bachelor’s degrees is a key issue for RNs inrural areas who want to become certified as CNMs,CRNAs, NPs, or other nurse specialists. Although

certificate-level advanced nurse training programsdo exist, their numbers are decreasing (263,673).Moreover, most organizations that certify advancednurses require a bachelor’s or master’s degree (263),and there have been movements in some Statestowards the bachelor’s degree as the entry-leveldegree in professional nursing (698). In fact, in themid-1980s North Dakota became the first State torequire a bachelor’s degree in nursing for RN

licensure (263).

Economic Factors

Economic concerns influence rural health person-nel recruitment and retention at many stages. In-creasing costs of health professions education can

Photo credit: Gai7 Mooney

Nurses in many rural hospitals are called upon toassume a wide range of responsibilities due to the

hospitals’ small size and limited resources.

Costs of Education and Student Indebtedness

Tuition in many health professions schools hasbeen increasing faster than inflation. During theperiod 1980-81 to 1986-87, average medical schooltuition increased by 125 percent for students attend-ing a public school in their State of residence (671).First-year tuition in osteopathic medical schoolsincreased by 17 percent from 1982 to 1984 alone(670). The average cost of tuition, fees, and other

expenses at United States medical schools in aca-demic year 1987-88 ranged from $13,765 for stu-dents attending public schools in their State of residence to $25,629 for students attending privatemedical schools (673) Tuition in all types of nursingprograms has also been increasing (673). In publiclysupported associate degree nursing programs, tui-tion increased by 65 percent from 1985-86 to



creasing costs of health professions education candiscourage students from choosing health careers.

Heavy educational debt loads, perceived or actualrural-urban income differentials, and reimbursementpolicies that penalize certain specialties or geo-graphic areas may influence practice choices. Othervariables, such as rising malpractice insurancepremiums, may also influence students’ and profes-sionals’ career and practice choices.

y p1989-90 (673).

Recent reductions in the availability of scholar-ships and other forms of financial aid have forcedmedical students to borrow more heavily in order tofinance their education (168). As costs of educationhave increased, so have the levels and frequency of indebtedness among health professional school grad-uates. A recent study of students in allopathic and


Table 12-3-Registered Nurses Employed in Nursing: Percent of Time Spent in Various Professional Activities andPercent Enrolled in Advanced Nurse Education Programs, by County Population Size, 1988

Percent distribution within each county size categorya

Counties Count i es Counties Count i es Counties

50,000 with fewer with 25,001 with 10,001 with 10,000

All U.S. or more than 50,000 to 50,000 to 25,000 or fewer

counties residents residents residents residents residents

Currentlyenrolled in education

program for nursing-related degree:Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 11.4 8.9 9.3 7.8 10.4 No.... . . . . . . . . . . . . . . . . . . . . . . . . . 88.3 88.1 90.8 90.4 92.1 89.6Unknown. . . . . . . . . . . . . . . . . . . . . . . . 0.5 0.5 0.2 0.3 0.2 0.0

Totalb

. . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0Percent time spent in:

Administration. . . . . . . . . . . . . . . . . 10.4 10.3 12.1 11.3 13.0 13.0Consultation. . . . . . . . . . . . . . . . . . . 6.5 6.5 5.9 5.4 6.8 5.8Direct patient care. . . . . . . . . . . . 64.6 65.0 60.8 62.1 59.1 58.5Research. . . . . . . . . . . . . . . . . . . . . . . 1.6 1.6 1.3 1.3 1.2 1.4Supervision. . . . . . . . . . . . . . . . . . . . 11.3 11.0 15.0 14.5 15.2 17.0Teaching. . . . . . . . . . . . . . . . . . . . . . . 5.1 5.2

4.44.8 3.9

4.1Other. . . . . . . . . . . . . . . . . . . . . . . . . . 0.4 0.4 0,5 0.4 0.7 0.1

Totalb

. . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0

acounty population size does not necessarily reflect metro or nonmetro ‘tatUs

.b

Percentages may not add to 100 due to rounding.

SOURCE: D.A. Kindig, University of Wisconsin, Madison, WI, and H. Movassaghi, Ithaca College, Ithaca, Ny,unpublished analysis of data from the 1988 National Sample Survey of Registered Nurses (provided by

the Division of Nursing, Bureau of Health Professions) conducted under contract with the University

of North Dakota Rural Health Research Center, Grand Forks, ND, 1989.

osteopathic medicine, dentistry, optometry, andveterinary medicine estimated that three-fourths of these students cover 70 to 90 percent of theireducational costs through loans averaging $10,000for each year they are in school (52). The averageeducational debt of senior allopathic medical stu-dents

13more than doubled from 1980 to 1989, from

$17,200 to $42,374 (61,671). In 1989, 81 percent of

senior allopathic medical students reported somelevel of educational debt, and 29 percent were indebt in excess of $50,000 (61). The average educa-tional debt of senior osteopathic medical studentsincreased by 30 percent from 1985 to 1988 alone,from $49,600 to $64,700 (21).

Indebtedness of other health professionals canalso be substantial. In 1987, the average debt of

pharmacy students (673). The average educationaldebt of baccalaureate nursing students in 1988 was

$10,056 in public institutions and $12,939 in privateinstitutions (19a).

14

Heavy debt loads may cause financial difficultiesfor physicians during specialty training and duringthe early years of practice. Hernried et al. estimatedthat a resident with $40,000 in undergraduate debtwho is training in a relatively inexpensive city willexperience a deficit of $4,890 during internship andwill have a negative cash flow throughout his or herresidency (254). Residents with debts in excess of

$80,000 may accumulate an additional debt of $75,000 or more during a 5-year residency program(254).



also be substantial. In 1987, the average debt of dental graduates was $39,000 (673). The amount

doubled from 1979 to 1984, and it has sinceincreased at an annual rate of 6 percent (673). In1987, average indebtedness was $33,600 for gradu-ating optometry students and $13,000 for graduating

Evidence on the relationship between indebted-

ness and location choice is scarce and inconclusive.A recent study of indebtedness issues by the Bureauof Health Professions (670) concluded that thecurrent scarcity of research on the effects of indebt-

lskcludes debt fiornprerne~c~ education. Included in the average are students who reported no educational debt.

14F3accalaureaten~~g student debt based ondatafrom case studies inordy IOfiti@tiO~.


edness on career and location choices maybe due inpart to the relative newness of high student indebted-ness. If educational costs and indebtedness levelscontinue to escalate at their current rate, financialconsiderations will probably become more promi-nent factors in students’ and graduates’ career andpractice choices.

Income and Practice Costs

Factors such as lower income and increasednumber of patients with inadequate insurance cover-age have been cited as sources of job dissatisfactionamong rural physicians (405,461). The extent towhich economic concerns such as these actuallyaffect health professionals’ location decisions hasnot been assessed directly, but perceived or actuallower income may serve as a disincentive to ruralpractice.

The incomes of rural physicians are lower andhave not increased as rapidly as the average incomeof all physicians (table 12-4) (68). Some of thesmaller increases are probably due to the fact thatmany rural physicians are primary care physicians,who have also witnessed relatively slow rises inincome. Less is known about rural/urban differencesin the incomes of other health professionals. PAs

practicing in smaller communities are more likely tohave low salaries than PAs practicing in largercommunities (table 12-5) (17). There are consider-able differences in average RN salaries amongcounties of different population sizes, with RNs inthe least populated counties receiving only 76percent of the annual salary of RNs in the mostpopulated counties (table 12-6) (317). The extent towhich these differences reflect cost of living or other

factors is unknown. Physician Income—Nearly 30 percent of physi-

cian income is from government sources, much of itfrom Medicare (68). Geographic variations in Medi-care payments for equivalent physician services,which can be considerable (152,396,475,609,615),have been a subject of considerable attention fromthe Physician Payment Review Commission (PPRC)

Table 12-4-income of U.S. Physicians (as aPercentage of Average Physician Income)by Specialty and Practice Location, 1977

through 1986a

Percent of averageUs. physician income

1977-78 1985-86

Income by specialty

General/family practice 82.8 68.3

Internal medicine 98.2 91.2Pediatrics 76.5 68.2

Income by geographic area

Nonmetropolitan areas 95.9 86.8

aData are an average ‘f 2

years ‘surveys.SOURCE : Reprinted with permission from P. G. Barnett

and J . E . Midtlin8, “Public Policy and theSupply of Primary Care Physicians , “ JAMA 262 (20 ) : 2864-2868, 1989, table 5 (Copyr~

1989, American Medical Association) . Based

on data from: M. L . Gonzalez and D. W. Em - mons , Socioeconomic Characteristics of Med-ical Practice 1987 (Chic ago , IL : Ameri can

Medical Association, 1987 ).

Table 12-5--Average Annual Salary Range ofPhysician Assistants by Community Size, 1989a

Community sizeb

Fewer than 10,000 to More than10,000 250,000 250,000

Salary range residents residents residents

Percent of physician assistants

Less than $20,000 . . . . . 5 3 4$20,000 -$30,000 . . . . . . . 20 17 12$30,000 -$40,000 . . . . . ., 44 46 41$40,000 -$50,000 . . . . . . . 20 23 26Greater than $50,000. . 10 10 15 None listed. . . . . . . . . . . 1 1 1

Totalc. . . . . . . . . . . . . . 100 100 100

aThi ~ in formation is derived from the Ame r i canAcademy of Physician Assistants’ 1989 Prescriptive

Practice Survey and is statistically representative

of member and nonmember physician assistants in

communities of all sizes.

bCommunity size does not reflect metro or nonmetro

10C at ion.cpercentages may not add to 100 due to rounding.

SOURCE : American Academy of Physician Assistants,

Alexandria, VA, unpublished data from the



the Physician Payment Review Commission (PPRC)and other interested parties. Payments within a given

locality to different practitioners who provide equiv-alent services also vary (475,562). These variationsare probably an underlying cause of geographicvariations in payment within a given physician

1989 PA Prescriptive Practice Survey provided to 01’A in 1989.

specialty, because methods for setting payment rates

for different specialists are not consistent among

Medicare’s insurance carriers15(652).

15M~i~~~ pm B ~~u~ement is ~dled through 48 ~~ance c~ers. ~ysici~ submit ~eir c~s to th e carriers for re imbmemen~ ~d me

carriers in turn submit reimbursement totals to the Health Care Financing Administration on a quarterly basis.


Table 12-6--Average Annual Salary of RegisteredNurses, by County Population Size, 1988

Average annualCounty population size

asalary

b

All U.S. counties . . . . . . . . . . . . . . . . . . . . $27,432

50,000 or more residents. . . . . . . . . . . 27,790Fewer than 50,000 residents. . . . . . . . 23,516

25,001 to 50,000 residents . . . . . . . 24,33610,001 to 25,000 residents. . . . . . . 22,774

10,000 or fewer residents. . . . . . . . 21,365

acounty ~pulation size does not necessarily reflect metro or nonmetro status.bAnnual earnings in principal position.

SOURCE: D.A. Kindig, University of Wisconsin, Madison, WI, and H. Movassaghi, IthacaCollege, Ithaca, NY, unpublished analysisof data from the 1988 National SampleSurvey of Registered Nurses (provided by

the Division of Nursing, Bureau of Health

Professions) conducted under contract with

the University of North Dakota Rural

Health Research Center, Grand Forks, ND,

1989.

Under Medicare’s current “customary, prevail-

ing, and reasonable” (CPR) method for determining

physician payments, which will remain in place until

1992 (see ch. 3), the United States is divided into

approximately 240 “prevailing charge localities”

administered by 48 insurance carriers. Within eachlocality, the carriers compute a “prevailing charge”

for each physician service (475). A 1986 survey of

39 carriers found that 5 carriers did not distinguish

among specialists in calculating the prevailingcharge, but that 17 carriers calculated a separate

“prevailing charge” for each specialty (6.52).

PPRC studied geographic variations in prevailingcharges for 13 procedures and found notable varia-

tions among urban and rural counties of different

sizes (table 12-7) (475). Prevailing charges weregenerally lowest in the smallest rural areas and

highest in the largest urban areas. After adjusting for

cost of practice, however, these variations evened

out considerably (table 12-7)16

PPRC concluded

Among the 13 procedures studied, charges forhospital and office visits to internists and FPsshowed substantially greater variations among lo-calities than did other services (475), a fact that maybe of particular significance in rural areas whereinternists and FPs constitute a larger part of thephysician population. A study of geographic varia-tions in Medicare surgical fees found that, bothbefore and after adjusting for practice costs, rural/

urban differences were much smaller than differ-ences across large urban areas (396).17 Wide varia-tion across rural areas of the same size has also beennoted. In 1984, for example, prevailing charges fora total hip replacement were $2,400 in rural Missis-sippi and $990 in rural Kentucky (475). Suchexamples are not isolated incidents, and they cannotbe explained by differences in practice costs alone(475).

Less is known about geographic and specialtyvariations in Medicaid reimbursement for physicianservices. By law, Medicaid is prohibited frompaying more than Medicare would for a particularservice (see ch. 3), although in practice it mayoccasionally do so. In many cases, however, Medi-caid appears to pay considerably less. Table 12-8compares Medicare and Medicaid payments for twocommon procedures in each State in 1986. Depend-

ing on the State, the maximum Medicaid paymentranged from 33 to 125 percent of Medicare’smaximum allowable charge for a brief followupoffice visit, and from 14 to 104 percent for anappendectomy (610). These percentages must beregarded with caution, because the analysis com-pared the highest Medicare-allowed charge any-where in a State to the average maximum Medicaidpayment statewide. However, the analysis does

illustrate the extreme variation in both Medicare andMedicaid reimbursement.

Rural physicians may be harder hit by lowMedicare and Medicaid reimbursement rates be-cause they have proportionately greater Medicareand Medicaid caseloads than those of their urbancounterparts. A recent survey of Minnesota physi-i f d h h di M di id l d



out considerably (table 12-7). PPRC concluded

that these analyses “cast doubt on the existence of major inequities between rural and urban areas in theaggregate,” but that greater inequities do existamong specific localities, both urban and rural (475).

cians found that the median Medicaid caseload was

15 percent in rural Minnesota compared with 5percent in the Twin Cities metro area (173). Ruralphysicians surveyed were more likely than physi-cians Statewide to report a recent increase in their

16PPRC uses tie Gcogrsphic practice Cost Index (GPCI) to adjust for geographic differences ~ cost of practice17~ese r~~chers SISO used the GPCI to adjust for practice ~s~.


Table 12-7—Average Prevailing Charges for Selected Procedures by Geographic Location, Actual and Adjusted

for Differences in Practice Costs, 1987 (In dollars)

County size and classif icationa

Large Small Large Small All

Procedure (specialist) urban urban rural rural count i es

Comprehensive office visit (internist) Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Comprehensive office visit (family practitioner) Actual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Limited office visit (internist) Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Limited office visit (family practitioner) Actual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hospital care,comprehensive (internist) Actual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hospital care, comprehensive (family practitioner) Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hospital care, limited (internist) Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Consultation, comprehensive (internist) Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

EKG, complete (internist) Actual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Chest x-ray (internist)

Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Upper GI endoscopy (gastroenterologist) Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gallbladder removal (general surgeon) Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cataract removal (ophthalmologist)

Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Multiservice index Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8376

7265

2624

2422

9487

8477

2927

116106

39

36

4440

361338

1,042966

1,8671,718

114104

7679

6365

2223

2121

8890

8183

2324

98100

36

37

3940

327334

893922

1,5931,628

9799

6976

5561

2022

1921

8090

7583

2123

8999

34

38

3741

313347

810907

1,5211,701

90100

6877

5360

1821

1820

7989

7180

2023

8596

33

37

3742

285321

794899

1,5631,776

8698

7777

6463

2323

2121

8889

8080

2525

102102

36

37

4041

335339

920933

1,6811,685

101101

aLarge urban = metro counties of 1,000,000 or more residents; small t.mban = metro counties with fewer than

1,000,000 residents; large rural = nonmetro counties with 10,000 or more residents; small rural = nonmetro

counties with fewer than 10,000 residents.

SOURCE: Physician Payment Review Commission, Annual Report to Congress: March 1988 (Washington, DC: March

988 8 8



1988), tables 8-5 and 8-7.

Medicaid caseload (78 percent v. 52 percent) (173). physicians v. 42 Percent of physicians in the TwinRural Minnesota physicians were also more likely Cities and 35 percent of physicians in Duluth andthan their urban counterparts to report recent in- Rochester metro areas), and in the proportion of allcreases in the proportion of their Medicare patients their patients who lack any form of basic healthwho are unable to pay their bills (61 percent of rural insurance (173).


Table 12-8-Medicaid Maximum Payments and Medicare Maximum Allowable Charges for Selected Services,

1986a

(In dollars)

Brief followup office visit Appendectomy

Medicaid as Medicaid as

Medicaid Medicare percent of Medicare Medicaid Medicare percent of Medicare

Alabama Alaska ArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisiana

Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey

New Mexico New York North Carolina North DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennessee

TexasUtah

Vermont Virginia Washington West Virginia Wisconsin Wyoming

Simple average

$11.7028.4112.0011.0411.75

8.80

b

12.6620.0010.0015.6013.2510.5011.5017.30 NA

15.0013.0010.698.0010.508.007.75

15.7511.5510.0011.3016.3015.826.009.00

11.507.oo

b

13.108.20

12.0011.0011.0713.0014.009.50

12.0018.00

NA 9.928.006.3013.9210.0016.2316.30

12.43

$20.7024.7014.4030.0015.50

24.8021.0025.00

C

24.8015.0016.5014.6025.0016.5030.0016.7016.5016.30 NA

22.00 NA

23.50 NA NA

20.7014.7016.3024.7012.4020.60

17.2020.60

d

16.50

12.40

20.60

20.70

18,50

25.00

20.63

14.62

12.40

14.40

24.75b

12.40

12.40

NA

17.7ob

16.50

18.10

14.40

18.56

56.5115.083.336.875.8

35.560.390.940.3104.080.371.946.0104.8 NA 89.878.865.6 NA 47.7 NA 33,0 NA NA 48.376.9

100.064.048.443.7

66.934.079.466.158.353.159.852.067.965.096.8

125.0

NA 80.064.5 NA 78.660.689.7113.2

67.0

$405.00 NA

275.00353.68280.00

276.00

b

390.35315.00197.50399.50453.66336.40270.00533.00

NA 268.00401.60411.16217.50202.00233.00271.50520.00295.05220.00342.88453.90673.72225.00211.00

396.15160.00378.00449.05337.50500.00387.98301.50205.00307.40345.00449.50

NA 430.12225.00236.25290.23230.00432.85483.50

337.97

$412.80 NA

412.60825.20433.20

700.00492.70515.60

C

674.60600.00660.10476.10605.00515.75500.00536.20515,75722.00536.40515.70515.75399.00519.90510.00567.40489.90453.90742.70

d

490.00660.20

579.601,140.20

536.40494.80515.75610.00577.60515.70515.75440.92455.80536.50

618.90d

NA 490.00515.60576.80515.75663.80464.30

557.47

98.1 NA 66.742.964.639.479.261.129.366,668.770.744.6103.3 NA 50.077.956.940.539.245.268.0

100.057.938.870.0100.090.745.932.0

68.314.070.590.865.482.067.258.539.769.775.783.8

NA NA 45.945.850.344.665.2

104.2

60.6

NOTE: NA = not available.



NOTE: NA not available.aMaxlmWs shon under Medicare and Medicaid are for physician specialist services,

unless otherwise noted. In many States, there is a lower Medicare maximum for general practitioners’ services; only a few Medicaid programs make this distinction. Medicaid maximums are statewide averages. Medicare maximums are thehighest allowable charges anywhere in the State.

haximum payment for general practitioner; Arizona had no general Medicaid program in 1986.

value for specialists is unavailable.cIncludes Maryland suburbs.dInformation available only for part of State.

SOURCE: U.S. Congress, Congressional Research Service, Medicaid Source Book: Background Data and Analysis,

House of Representatives Comfnittee on Energy and Commerce, Print No. 1OO-AA (Washington, DC: U.S.

Government Printing Office, November 1988), tables G-3 and G-4.


Physician Practice Costs—A Medical Econom-ics survey of 1987 physician practice costs foundthat rural physicians had higher mean professionalexpenses than did their urban and suburban counter-parts (269). This same survey showed that solophysicians’ practice costs accounted for a percent-age of their gross income greater than that forphysicians in group practice.

18American Medical

Association data indicated that median professional

expenses for rural G/FPs were $14,000 higher thanthose for G/FPs in the largest urban areas in 1988(218).

Although surveys of physicians such as thesesuggest rural practice costs are higher than urbanones, other data show per-unit rural costs to belower. While AMA and Medical Economics data arebased on reported annual outlays per physician,Medicare uses the Geographic Practice Cost Index,

which uses per-unit input prices for the variouspractice cost components (e.g., nonphysician em-ployee salaries, malpractice insurance premiums,equipment costs), to set fees for specific services.These per-unit costs are generally lower in rural thanin urban areas (475).

Medical malpractice liability insurance premiumsas a percentage of gross income have increased more

dramatically for providers of obstetric care than forother medical specialties, although these increasesnow appear to be leveling off (figure 12-2) (36,218).High premiums may discourage physicians andCNMs from practicing obstetrics, particularly inareas where volume of cases is low, or where womencannot pay the full costs of care. (The impact of rising malpractice insurance premiums on the avail-ability of rural obstetric services is discussed in

greater detail inch. 15.)Dramatic variations in physicians’ malpractice

insurance premiums exist among States. For exam-ple, in 1985, annual premiums for OB/GYNs inFlorida (excluding Dade and Broward Counties),Arkansas, and North Carolina were $92,830,$18,950,and $15,290, respectively (636). Premiums in theseStates for general practitioners providing minor

$16 700 $3 700 d $3 000

Figure 12-2—Average Liability Insurance Premiums asa Percent of Average Gross Income* of Self-Employed

Physicians in Selected Specialties,b 1982-88

Percent of gross income

‘2~ I

o~I

1982 1983 1984 1985 1986 1987 1988

* Obstetrics/gynecology

+- Surgery

+ Internal medicine

+– Family/general practice

Wean net income plus mean professional expenses.bDoes not include osteopathic phystians.

SOURCE: Office of Technology Assessment, 1990. Data from M.L.Gonzalez and D.W. Emmons, %eioeconomic Characteristics of hfedical Practke 1989 (Chicago, IL: Ameriean Medieal Associa-tion, 1989); and Ameriean Medieal ASoeiation, Center forHealth Policy Research, Socioeconomic Charactensfics of Mecka/ Practice 7987 (Chicago, IL: 1987).

Although more challenging to translate into

purely economic terms, certain other practice ‘costs”may be higher for rural than for urban physicians,such as:

q

longer work and on-call hours (figure 12-1),

higher costs of maintaining medical equipmentdue to technician travel costs,

difficulty subsidizing through patient revenuesthe costs of maintaining expensive but infre-



surgery were $16,700, $3,700, and $3,000, respec-

tively (636).19 No studies have been conducted todate to determine the direct effects of premiumincreases on providers’ choices of practice location.

q

the costs of maintaining expensive but infre-

quently used medical equipment, andhigh volumes of uncompensated care for somephysicians.

18ppRc f~~d ~ub~~tial &fferenc~ fi tie f@es report~ by MS s~ey md Otiers conducted during the same the ptiod (47’5).

19AU figURS me for the same degree of coverage.


Concerns of Allied Health Professionals 20

A Florida study (572) found that the greatestproblems with the recruitment and retention of alliedhealth professionals (AHPs) in Florida’s small ruralhospitals were general short supply of AHPs anddifficulty in recruiting AHPs to work in rural areas.Recommendations of the study included:

q

q

q

q

development of cross-training programs,

recruitment of students from rural areas,development of rural training sites, and

formation of networks through which ruralhospitals could share the services of certainhard-to-find AHPs (572).

State licensure requirements for AHPs were alsocited as a barrier to rural recruitment and retention(572). Small rural hospitals were particularly dissat-isfied with Florida’s licensure requirements forrespiratory therapists, laboratory technologists andtechnicians, and radiologic personnel. Some hospi-tals indicated a need to broaden certain licensurerequirements to permit personnel to perform a widerrange of functions, while others recommended thatlicensure requirements be narrowed for hospitalsthat provide a more limited range of procedures.Some hospitals noted that practice regulations are insome cases too stringent, and that certain AHPs

should be permitted to function with less directsupervision. For example, Florida law preventslicensed laboratory technicians from performingprocedures (e.g., drawing blood, plating cultures)when a licensed medical laboratory technologist isnot physically present in the room (572).

Although fulfilling continuing education require-ments was cited as a problem for Florida’s rural

AHPs, hospitals and professional organizations feltthat current requirements were appropriate andshould not be changed due to the provider’s location(572).

Multiskilled AHPs

Small rural facilities that have a lower volume of specific services may not need full-time specialized

radiology services and medical laboratory services,

but it maybe fiscally unable to hire both a certifiedradiologic technologist and a certified medicallaboratory technologist. Furthermore, a fully certi-fied medical laboratory technologist may be over-qualified for work in a facility that only provides alimited range of services. Ideally, such a facilitywould hire a single individual who was certified inboth fields, but such individuals are in even shortersupply than single-skilled AHPs.

There are two major barriers to the use of multiskilled AHPs. First, there are few programs thatoffer formal cross-training for AHPs. It is not knownhow many of these, if any, are in rural areas. Somehospitals provide formal on-the-job training for theirmultiskilled AHPs (424), but this involves a com-mitment of resources that small rural facilities may

not have.

Second, State licensure and regulation policies insome cases do not permit limited licensure of healthprofessionals--i.e., licensure for a narrower range of skills than the profession typically performs. Return-ing to the example above, the rural intermediate carefacility may not require the full range of skills thata fully trained and certified radiologic technologist

could offer. Ideally, the facility would train acertified medical laboratory technologist to performa more limited range of radiologic tasks (e.g., simplex-rays). This solution would be feasible only if theState offered limited licenses for radiologic technol-ogists or had more flexible staffing requirements forintermediate care facilities. It is likely that informalcross-training of AHPs has been occurring in ruralfacilities for some time, but in some instances the

use of such professionals may fall outside theproscriptions of State laws and regulations.

In its 1989 report, the Institute of Medicine’sCommittee to Study the Role of Allied HealthPersonnel described licensure as the “most restric-tive type of regulation” and concluded that “itseffectiveness in protecting the public has not beenconclusively demonstrated’ (288). The Committee



specific services may not need full time specialized

AHPs, but they may be required to hire certain typesof personnel in order to provide those services. Forexample, a remote rural intermediate care facilitywould be required to provide limited diagnostic

conclusively demonstrated (288). The Committee

recommended that States increase flexibility incurrent licensing laws to allow more overlap inscope of practice for some occupations and to allowalternative routes to licensure (288).

resee CL 10 for a &xcriptiOn of allied health p~fessiom.


SUMMARY OF FINDINGS

Factors Affecting Physician Specialty Choice

Unfortunately for the future supply of ruralphysicians, physicians are increasingly choosing nonprimary care specialties. Reasons for this trendinclude perceptions that primary care practice is lessintellectually challenging and more demanding intime and effort. Lack of faculty role models in

primary care maybe an additional factor. preferencefor nonprimary care specialties has also been linkedto expected earnings and to high levels of indebt-edness.

Public medical schools produce a larger pro-portion of primary care physicians than do privateschools, and some States and regions send relativelyhigh proportions of their medical graduates into

primary care. Receipt of a Federal scholarship (e.g.,NHSC) is also strongly associated with the choice of primary care.

Factors Affecting Location Choice

Physician location decisions are more depend-ent on personal and professional than on financial

factors. Factors such as preference for rural or urbanliving, availability of recreational, social, and cul-tural activities, adequate backup facilities, opportunityfor professional consultation and continuing educa-tion, shorter work hours, and opportunity for grouppractice have been identified as key determinants inthe choice for rural or urban practice. Employmentopportunities for spouses may also play a key role inthe location decisions of young physicians. Otherfactors strongly associated with the decision forrural medical practice include lower socioeconomicbackground, experience in the National HealthService Corps, and participation in a loan forgive-ness program tied to service obligation.

For nonphysicians, job satisfaction is more heavily influenced by professional autonomy and opportunities for career advancement. However,financial considerations may be important in theinitial recruitment process.

vacation or continuing education leave. These prob-lems may also apply to MLPs in isolated rural areas.A strong preference for group and salaried practice,most often found in urban areas, has been notedamong medical residents. Studies examining t h eimpact of hospital closures on rural physician supplyare inconclusive or conflicting.

Lack of opportunities for career advancement andpoor access to continuing or advanced educationmay dissuade nurses from choosing rural practicelocations. For nurses already in rural areas, lack of educational resources may prevent them from seek-ing advanced nursing degrees, thus stifling a poten-tial source of rural nurse MLPs.

A major barrier to the utilization of MLPs in autonomous settings is the limited coverage for their services under Medicare, Medicaid, and other

third-party plans. Restrictive State practice acts can also present barriers to the utilization of MLPsin independent rural settings. Although third-partyreimbursement for MLPs has improved during thepast decade, it is still limited to certain settings, andit is usually indirect rather than direct.

Recruitment and retention of some AHPs in regulated rural settings, such as hospitals and

nursing homes, are hindered by limitations of Statelicensing laws that do not permit the cross-licensing of AHPs to perform broader ranges of

functions.

Economic Concerns

The costs of medical and other health professionseducation have risen sharply in recent years. Studentindebtedness has also increased dramatically and is

particularly pronounced for medical graduates. Al-though there is as yet no conclusive evidence of theeffect of indebtedness on location choice, theincreasing preference among medical graduates

for salaried practice suggests that economic concerns such as indebtedness do play a role in practice decisions, and they may dissuade recent graduates from establishing private practices in rural areas.



p

Personal and Professional Concerns

Compared with urban physicians, physicians in rural areas work longer hours, see more patients per week, and have more office visits per week. Solopractitioners in isolated rural communities may havecontinuous hours, with little or no opportunity for

The average incomes of both primary care physi-cians and rural physicians have increased moreslowly than those for other physicians. Based on thelimited information available, it appears that phy-

sicians in rural practice care for a larger percentage of Medicare, Medicaid, and uninsured patients than their urban counterparts. Thus they may be


penalized by low reimbursement rates (particularlyfor Medicaid patients) and higher volumes of uncompensated care. In addition, many “intangi-ble” costs may be greater for rural than for urbanphysicians (e.g., longer work hours and costs of maintaining frequently used equipment).

It remains unclear to what extent rising mal-practice insurance costs are affecting the outmi-gration, immigration, or practice of rural health

professionals. Obstetric care providers face particu-larly high premiums. Premiums have increasedrapidly during the last decade, but they are nowbeginning to stabilize. The impact of the “liabilitycrisis’ may be greater on rural than on urban areasdue to lower caseloads among rural practitioners andhigher proportions of lower paying patients.

PAs and nurses in smaller communities have

lower incomes than those in larger communities, but

it is not clear to what extent these differences reflect

cost of living or other factors.

Low operating margins make it difficult for many

rural health facilities to compete for AHPs and

nurses in the national labor market by raising

salaries and offering other incentives. In addition,

licensure requirements can limit the use of multi-skilled AHPs in small rural facilities that neither

need nor can afford to employ several AHPs to

perform separate functions.



Chapter 13

Strategies To Recruit and Retain

Rural Health Professionals

CONTENTS Page

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

335EDUCATIONAL STRATEGIES: PREPARING HEALTH PROFESSIONALS FORRURAL PRACTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

Medical Education Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335Educational Strategies For Other Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339The Area Health Education Centers (AHEC) Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343

STRATEGIES TO REDUCE PROFESSIONAL ISOLATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346Consultative and Educational Opportunities Through Telecommunications . . . . . . . . . . . . . . . . . 346Opportunities for Vacation and Educational Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348

FEDERAL STRATEGIES TO ADDRESS ECONOMIC CONCERNS .... +... . . . . . . . . . . . . + .348

The Resource-Based Relative Value Scale (RBRVS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348Medicare Bonus Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350

TARGETED STRATEGIES FOR AREAS OF ACUTE AND CHRONIC SHORTAGE . . . . . . . 351The National Health Service Corps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352Service-Contingent Scholarships for Nurse Practitioners and Nurse-Midwives . . . . . . . . . . . . . . 358Satellite Clinics and Increased Utilization of MLPs in Rural Areas . . . . . . . . . . . . . . . . . . . . . . . . 359

RECRUITMENT AND RETENTION IN THE PRIVATE SECTOR . . . . . . . . . . . . + . . . . . . . . . . + 359Local Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . +... . . . . . . . . . . . + 359Communityand Migrant Health Centers ..,... . . . . . . . . . . . . . . . . . . . . . . . . . .. ... ... ... ..~~. 360



STATE EFFORTS IN HEALTH PERSONNEL DISTRIBUTION . . . . . . . . . . . . . . . . . . . . . . . . . . 361State Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

Characteristics of Program Success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362

SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366

General Strategies for Rural Recruitment and Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366

Medicare Reimbursement Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

Strategies for Acute and Chronic Shortage Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367Private Sector Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368

State Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368

BoxesBox Page

13-A. Wanted: Rural Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33613-B. The WAMI Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33713-C. Example of a Rural-Oriented Training Program for Nurse Practitioner . . . . . . . . . . . . . . . . . 34113-D. Selected Area Health Education Center (AHEC) Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . 344

13-E. Examples of Midlevel Practitioner and Satellite Clinics in Rural Areas . . . . . . . . . . . . . . . . . 360

Figures Figure Page

13-1. Distribution of Area Health Education Center (AHEC) Programs by State, 1988.........34713-2. Funding Levels and Source of Funding for State Health Professions Distribution Programs,

1980 and 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36513-3. Focus of 112 State Health Professions Distribution programs Identified by the Bureau of

Health Professions, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365

TablesTable Page

13-1. Federal Support for Physician Assistant Training Programs, Fiscal Years 1972-1989,...34013-2. Federal Grants and Cooperative Agreements Awarded in the Allied Health Area,

Fiscal Years 1967-1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34313-3. Location and Funding Status of Area Health Education Center (AHEC) Projects . . . . . . . 34513-4. Federal Funding of the Area Health Education Centers (AHEC) Program,

Fiscal Years 1978-1990; and Impact of the AHEC Programs, Fiscal Year 1988.........346

13-5. Changes in Physicians’ Medicare and Total Revenues Under Medicare’s Resource-BasedRelative Value Scale (RBRVS), by Specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34913-6. Change in Medicare Payments Under Medicare’s Resource-Based Relative Value Scale

(RBRVS) in Metropolitan and Nonmetropolitan Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34913-7. National Health Service Corps: Funding and Participants in Field, Scholarship, and

Loan Repayment programs, Fiscal Years 1971-89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35313-8. Volunteer Placements Made Through the National Health Service Corps (NHSC)

Recruitment Branch, 1988 and 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35413-9. Federally Salaried Personnel in the National Health Service Corps (NHSC) by

Obligation Status, 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355

13-10. National Health Service Corps Providers by Discipline, 1981 and 1989 . . . . . . . . . . . . . . . . 35513-11. States Officials’ Ratings of the Effectiveness of Selected Federal Programs in

Improving the Availability of Health Services in Nonmetropolitan Health PersonnelShortage and Medically Underserved Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362

13-12. State Health Professions Distribution Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36313-13. States’ Level of Effort in Health Professions Distribution Compared With Their

Underserved Nonurban Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364



Chapter 13

Strategies To Recruit and Retain Rural Health Professionals

INTRODUCTION

Faced with threatened or actual shortages of health care professionals, rural communities re-spond by attempting to retain existing professionalsand recruit new ones (box 13-A). The economic,

geographic, and social disadvantages of some ruralareas, however, continue to limit their ability tocompete effectively for health professionals. Theprevious chapter examined factors that may influ-ence the specialty and location decisions of healthprofessionals. This chapter examines and evaluatesvarious strategies that have been used to recruit andretain health professionals in rural areas. Theseinclude focused educational strategies (e.g., primary

care and rural-oriented health professions educa-tion), strategies to reduce professional isolation(e.g., telecommunications networks for rural healthpersonnel), strategies to address economic concerns(e.g., improving reimbursement to rural and primarycare physicians), and targeted strategies for the mostsevere shortage areas (e.g., service-contingent loansand scholarships and the development of satelliteclinic networks).

EDUCATIONAL STRATEGIES:

PREPARING HEALTH

PROFESSIONALS FORRURAL PRACTICE

This section examines educational strategies torecruit and retain rural health professionals and

describes Federal programs that may contribute tosuch strategies. It also describes specific projectsthat do not necessarily receive Federal funding butmay be models for new or expanded Federal andState initiatives.

Medical Education Strategies

Special experiences during medical education canhave a strong positive influence on physicians’

interventions on physicians’ choices of specialty andpractice location is difficult to determine. Manyprograms that use such interventions, however,place a large percentage of their graduates in ruralpractice sites. Available evidence suggests thatcomprehensive programs are more successful than

brief rural preceptorship or residency rotations ininfluencing the decision for rural or primary carepractice (150).

In addition to providing targeted funding to healthprofessions training programs, the Federal Govern-ment has also sponsored a number of studentassistance programs, including the Exceptional Fi-nancial Need Scholarship Program, the Health

Professions Student Loan Program, and the HealthEducation Assistance Loan Program. The FederalGovernment also provides student assistance indi-rectly through traineeship grants to educationalinstitutions (see ch. 3, table 3-l). These programsaffect both urban and rural students, but informationregarding the numbers of rural participants is notavailable. The Health Careers Opportunity Programand other programs administered through the Bureau

of Health Profession’s (BHPr’s) Division of Disad-vantaged Assistance have supported training formore than 50,000 disadvantaged and minority stu-dents since 1977 (675). These programs have effec-tively encouraged disadvantaged and minority stu-dents to enter health professions training programsand helped retain them in such programs.

Undergraduate Medical Education

The Federal Role--Federal support of under-graduate primary care medical education is limitedto family practice. Section 780 of the Public HealthService Act authorizes grants to establish, maintain,and improve departments of family medicine inmedical schools. Funding under this section de-creased by 30 percent between 1981 and 1988 (from$9.5 million to $6.6 million) (671).

Examples of Rural-Oriented Undergraduate Pro-



g p p ydecisions to practice primary care and to practice ina rural area (72,165,212,442,443376). These experi-ences include primary care-oriented undergraduatecurricula, rural preceptorship and residency rota-tions, and other types of decentralized educationalmodels. The true impact of particular educational

p f g grams-some schools require students to partici-pate in rural-oriented training. The University of Nebraska School of Medicine requires an 8-week rural preceptorship during the junior or senior year,where students work in a rural medical practiceunder the supervision of a local physician “precep-

–335–


Box 13-A—Wanted: Rural Physician Parkers Prairie,Minnesota: In the summer of 1989, the district

hospital in the farming town of Parkers Prairie, Minnesota(population 917) offered a $5,000 reward to anyone who couldfind a family practitioner (472). A “wanted” poster and a coverletter were sent to every doctor and medical student inMinnesota, Nebraska, North Dakota, and South Dakota; theposter was put up in strategic places from Parkers Prairie toMinneapolis, advertising the $50,000 to $75,000 position (472).

The bounty and advertised salary were apparently not highenough, and after several months the hospital was forced to hirea recruiting firm (581). The firm will charge from $12,000 to$20,000, regardless of whether it succeeds in finding aphysician, and is urging the hospital to increase the salary to$125,000 (581). As of March 1990, Parkers Prairie still had notfound a physician. It had also lost its administrator to aneighboring hospital that offered a better salary and benefits(581).

The 21-bed hospital’s sole physician reports that theS5,000 REWARD

hospital is heavily in debt and is in For a Family PracticeMedical

Doctor.imminent danger of closing(581). With three physicians, the hospital might be able to Graphics reptinted w“th permission of Administrator,

Parkers Prairie District Hospital, Parkers Prairie, MN generate enough patient revenue to survive. The presence of larger hospitals in neighboring communities may also contribute to the hospital’s financial difficulties by drawinglocal patients away. If the hospital does close, its physician plans to remain in the community in private practice,referring patients to a hospital 20 miles away (581).

According to a survey conducted by the Minnesota Hospital Association, 78 percent of Minnesota’s ruralhospitals were actively recruiting physicians in 1989 (173). Like Parkers Prairie, few of them were successful; onthe average, hospitals had been searching for 17 months (173).

Delta, Utah: The administrator of a medical center in the desert town of Delta, Utah (population 8,000) alsoresorted to a bounty system to find a physician. One of the town’s three physicians had left, and during the 4 monthswithout a replacement, the other two doctors were “worked to death” (259). After professional recruitment firmsfailed to find a physician, the administrator enlisted the entire Delta community in the search, offering $5,000 asfinder’s fee for a family practitioner who would agree to practice in Delta for at least 3 years. The communitysucceeded. All three attractive candidates who emerged within 2 months after the bounty was announced wererelatives of Delta residents. The reward went to a man whose father-in-law agreed to move his general practice fromSlidell, Louisiana to the Utah town in September of 1989 (259). Slidell, a community of over 12,000 residents,remains adequately served by 13 primary care physicians (156).

tor.” A survey of past participants found that the experiences with preceptor faculty (165). At thepreceptorship ‘had been-a significant factor in thechoice to enter residencies in a primary carespecialty (72). The Kirksville College of Osteo-pathic Medicine in Kirksville, Missouri requiressenior students to complete a 4-month rotation in arural satellite clinic (165). The clinics are located ineight communities that have no resident physician,

University of New Mexico, all medical studentsmust spend at least 1 month of clerkship time in arural area (573).

Other schools offer rural-oriented training on anelective basis. The University of New MexicoSchool of Medicine offers a special Primary Care



and students are supervised by faculty preceptorswho visit each site daily. The rural clinics experiencewas found to be the most influential factor in thechoice for malpractice location among graduates of the college. Other factors associated with the choiceof a rural practice location were rural origin and

Curriculum track as an alternative to the moretraditional curriculum (573). The special curriculumemphasizes self-directed learning and patient prob-lem analysis in order to better prepare the physicianto practice with confidence in remote settings wheretrained consultants may not be available. During the

Chapter 13-Strategies To Recruit and Retain Rural Health Professionals q 337

first year of study, a student spends a full 4 monthsin a rural area of the State under the direction of anapproved preceptor, learning what it is like to liveand work in a rural area (573). Thirty-one percent of the students in the special track have chosen familypractice as a specialty, compared with 10 percent of students in the traditional track (353).

Another example of an elective program is theRural Physician Associate Program at the Universityof Minnesota Medical School. Created in 1970, the

program provides a 9- to 12-month rural clinicalpreceptorship for third-year medical students (702).Of all former program students in practice in 1986,57 percent were in communities of 10,000 or fewerresidents. The program has played a major role inimproving the primary care physician-to-populationratios in Minnesota’s rural (nonmetropolitan) coun-ties. Studies comparing program and nonprogramstudents at the medical school indicate that students

participating in the program have higher levels of confidence in behavioral, surgical, verbal, andinterpersonal skills than do nonparticipating stu-dents, as well as higher degrees of computer literacy(702).

To reduce isolation and improve the quality of education received by students at remote trainingsites, schools can use telecommunications networks

to link these sites directly to the sponsoring institu-tion. For example, the University of Utah School of Medicine’s rural family practice preceptorship pro-gram uses microcomputers to provide students inremote sites with the opportunity to conduct activemedical literature searches (235). Participating stu-dents reported feeling less concerned about theirability to keep up-to-date on the latest medicalknowledge, and felt more confident in their own

skills (235).

1

In addition to providing rural clinical trainingopportunities, some schools have decentralized themost basic components of medical education inorder to influence the location choices of theirgraduates. Perhaps the best known example of adecentralized medical education program is theWAMI program (see box 13-B). Since the programbegan in 1975, it has largely achieved its original

l f i i h hi di ib i f

Box 13-B—The WAMI Program

In 1971, the WAMI (Washington-Alaska-Montana-Idaho) Program was established to improve thegeographic distribution of physicians within thefour-State area, which encompasses almost one-fourth of the total landmass of the United States(4).The University of Washington in Seattle, having theonly medical school in the entire region, agreed toaccept 20 students each from Montana and Idahoand 10 students from Alaska into each year’s

medical school class. In 1975, the program wasdecentralized in order to further improve distribu-tion of general/family practitioners throughout theregion. The first 2 years of training are now takenat the University of Washington School of Medi-cine in Seattle and at smaller institutions such as theUniversity of Alaska at Fairbanks and MontanaState University in Bozeman. During the third andfourth years, or the “clinical phase” of the pro-gram, all students participate in clerkships in family

practice, internal medicine, obstetrics and gynecol-ogy, pediatrics, and psychiatry in Seattle as well asin 17 more remote towns throughout the WAMIregion. Graduate residents in family practice, pedi-atrics, internal medicine, and psychiatry at theUniversity of Washington also rotate service inrural areas throughout the WAMI region (4).

A study of 42 WAMI alumni practicing in Alaskain 1986 (179) found that 52 percent were practicingin small towns and 91 percent were in familypractice. The amount of time spent in Alaskaclerkships positively correlated with the number of graduates choosing to practice in small Alaskantowns. Of graduates in small towns, 36 percentreported that without the WAMI program theywould have been unable to attend medical school(179).

program experience were practicing in rural areas in1981, compared with 13 percent of all U.S. physi-cians (4). Of graduates with WAMI experience, 61percent were in primary care practice (familypractice, general practice, general internal medicine,or general pediatrics), compared with 35 percent of all U.S. physicians (4).

Selective Admission of Rural Students—An-

h d b di l h l i



goal of improving the geographic distribution of physicians in the four-State area. A recent studyshowed that 23 percent of graduates with WAMI

other strategy used by some medical schools isselective recruitment of students predisposed torural practice (e.g., students with rural backgrounds).

1~~ project was ~d~ in part by the National Library of M@c~e.


Medical schools that have changed admission poli-cies to favor rural students have increased the

number of graduates who chose rural and underserv-ed practice (154,375,498,499). For example, grad-uates from the Physician Shortage Area Program atJefferson Medical College in Philadelphia, whichrecruits such students, were 7 to 10 times more likelythan other graduates to practice family medicine inrural or underserved areas (499).

A study of the rural-oriented primary care medicalschool curriculum at Michigan State University’s

Upper Peninsula campus found that most UpperPeninsula graduates were themselves from ruralareas (100). Graduates were more likely than their“down state” counterparts to choose rural practiceand family practice (100). At the Kirksville Collegeof Osteopathic Medicine in Missouri, about 50percent of the students who graduated between 1930and 1984 came from towns of fewer than 25,000residents (165). In 1981, students from smaller

towns were much more likely than students fromlarger towns to be practicing in rural areas (165).

Unfortunately, rural youth may be discouragedfrom choosing a medical career because of poorersecondary educational resources in some rural areas(325) or because of the high costs of medicaleducation. As noted in chapter 12, the proportion of enrolled medical students who are from rural areasdecreased by almost one-third between 1978 and1986 (500).

Graduate Medical Education

The Federal Role—The Federal Government,through the Medicare program, funds graduatemedical education (GME) in all specialties byreimbursing hospitals for costs associated with sucheducation. In addition, the Federal Government

subsidizes both undergraduate and graduate primarycare training programs and demonstration projects inrural areas.

Medicare reimbursed hospitals approximately $3billion in 1988 (672).

2Recent and proposed reduc-

tions in Medicare reimbursement for GME costs(138) have caused particular concern among primarycare residency programs. Studies have shown thatfamily practice (FP) residency programs--especially.those in ambulatory care settings--cannot usuallycover their costs through patient care revenues(128,139,305,464). Reduced funding may lead hos-pitals to reduce the number and size of theirresidency programs; if so, those programs most

likely to be discontinued are primary care residen-cies, which contribute the least to hospital revenues(113,138).

Critics of the current medical education systemhave recommended that more primary care specialtytraining programs be moved to the ambulatory caresetting, where most primary care medical practiceoccurs (338,521,606). Development and mainte-nance of ambulatory care training programs would

probably require further targeted funding to helpoffset some of their additional costs.

3

Federal funds to encourage the production of primary care physicians have decreased consider-ably over the past decade. Federal grants to FPresidencies decreased by 25 percent from 1980 to1988, from $27.1 million to $20.2 million

4(676).

Federal grants to general internal medicine and

general pediatric residency programs decreased by28 percent during the same period, from $19.3million to $13.9 million (68).

5

The Omnibus Budget Reconciliation Act of 1987(OBRA 87)

6authorized a program to fired four Rural

Health Medical Education Demonstration Projects.Under this program, hospitals sponsoring residencyprograms apply for grants to develop 1- to 3-monthclinical experiences at small rural hospitals for

physicians who have completed 1 year of residencytraining. Participating residents receive stipends andbenefits based on the reimbursement rate of the

Z’r’his amount included nemly $1 billion in direct costs (e.g., teaching costs, residents’ salaries, administrative expenses) and just Over $2 billion inindirect costs (additional operating costs assumed to be associat~ with the teaching function--e.g., increased use of ancillary services; increased costof high-tech testing and treatment facilities).3Ce~ GM E COSLS IIMy be higher in ~dato~ care settings, due to differences in the logistics of teaching in these settings. For example, fewm

students may be involved in an ambulatory visit than during a lengthier hospitalizatio~ and the increased duration of ambulatory visits due to studentinvolvement may decrease the total patient volume of the facility hosting the program (672). Before 1986, Medicare only reimbursed for outpatient careeducation if it was provided in hospitals. The Omnibus Budget Reconciliation Act of 1986 (Public Law 99-509) broadened reimbursement to included ti l t i t ti t tti h h it l i d “ ll b t ti ll ll” f th t i i t



educational costs in any outpatient care settings where a hospital incurred “all or substantially all” of the training cost.4Fu@ng is autho~ed under section 786(a) of the Public Health Service Act. Figures do not include funding for faculty development prOJ=ts.

5Fm~g is authofied under Section 784 of the Public Health Service Act. Figures do not include funding for faCu@ development prOJats.

@ublic hW 100-203.

Chapter 13--Strategies To Recruit and Retain Rural Health Professionals q 339

sponsoring hospital rather than that of the small rural

hospital, and payment to the sponsoring hospital isadjusted for additional costs unique to the program.The demonstration objectives are to determineappropriate components for rural residency pro-grams and to show how such programs can beduplicated in other areas at minimal cost. TheOmnibus Budget Reconciliation Act of 1989 (OBRA89)

7expanded the number of demonstration projects

to 10. Projects began in mid-1989 and last for 3

years.

Examples of Rural Oriented Graduate Programs—A unique program in Montana, a State with no FP

residency program of its own, provides satelliterotations in rural Montana communities for FPresidents from about 80 out-of-State programs(442,443). Participating residents complete theirrotations under the supervision of board-certified

physicians. The program has not only enabledMontana to attract residency graduates from otherStates, but it has also helped to improve thegeographic distribution of physicians within theState (442,443).

A pediatric residency program at a medical centerin Hanover, New Hampshire places medical resi-dents in rural pediatric practices viewed as “teach-

ing laboratories, ” where they are exposed over a3-year period to various aspects of rural practice. Of the first 14 residents to complete the program, 12were in primary care practice in 1985 and 8 werepracticing in rural locations in various States (309).A general surgery residency program at the Univer-sity of Louisville in Kentucky provides optional

rotations in rural areas. A survey of physicians who

graduated from the program between 1972 and 1981

found that a significantly larger percentage of thosewho were practicing in rural than in urban areas had

participated in the optional rotations (57).

A program launched in 1979 at the Marshall

University School of Medicine allows FP residents

to take 1-3 years out of their training to practice in

underserved communities while earning masters’

degrees in community health. The program director

believes that ‘‘this program has accounted for more

West Virginia than any program besides the Na-

tional Health Service Corps” (533).Decentralized residency programs also provide

unique opportunities for faculty and can contributeto the well-being of both sponsoring and localhospitals. A rural teaching practice operated throughthe Department of Family Medicine at the StateUniversity of New York at Buffalo is composed of

a four-physician group practice serving two rural

communities (529). The four physicians are full-

time faculty at the university, and the group practice

provides unique rural educational experiences for

medical students, residents, and fellows. The prac-

tice more than covers its annual costs, represents a

substantial portion of the primary care referral base

at the university teaching hospital, and has contrib-

uted to stabilizing the occupancy rates of local rural

hospitals (529).

Educational Strategies For Other Health Professionals

Midlevel Practitioners (MLPs)

The Federal Role—The Federal Government hassupported PA training programs for nearly two

decades (table 13-1). Since a major decline in 1982,

funding has remained relatively stable. Approxi-

mately three-fourths of the 52 PA training programs

in operation in 1989 received Federal support (192).

Some of the federally funded PA programs have a

rural focus, and all are mandated to encourage their

graduates to practice in health personnel shortage

areas. Continued support of PA training programs,

particularly those with a rural orientation, is likely to

have a positive effect on rural PA supply.

The Federal Government also supports the train-

ing of certified nurse-midwives (CNMs), nurse practitioners (NPs), and certified registered nurse

anesthetists (CRNAs) through the Nurse Practition-

er and Nurse Midwifery grant program and the Nurse

Anesthetist Traineeships and Programs grant pro-

gram. Although these programs are not entirely

dedicated to the training of students for rural

practice, they do fund some rural-focused8 projects.

Funding for the Nurse practitioner and Nurse-

Midwifery grant program changed little between



believes that this program has accounted for moreyears of physician service in underserved areas of

Midwifery grant program changed little between1980 and 1990-from $13.0 million to $13.4 million

7~bliC ~w 101.239.

sc~ss~lcation of a feder~ly tided nurse training project as “rural-focused” is based on the appearance of the tie te~ “-” in tie PmW~description.


Table 13-1—Federal Support for Physician Assistant Training Programs, Fiscal Years 1972-1989

Total number Authority

aFiscal year Amount funded of programs

HMEIA Contracts 1972 $ 6,090,109 40Section 774(a) 1973 6,208,999 39

1974 8,129,252 431975 5,994,002 401976 6,247,203 41

Section 701(8) 1977 $ 8,171,441 39and 1978 8,685,074 42

Section 783(a)(1) 1979 8,453,666 421980 8,262,968 431981 8,019,000 401982 4,752,000 341983 4,752,000 341984 4,414,850 341985 4,442,076 371986 4,548,000 361987 4,275,000 361988 4,549,973 37

Sections 701(8) and 788(d) 1989 4,452,000 38

aPublic Health Service Act.

SOURCE: U.S. Department of Health and Human Services,Health Resources and Services Administration, Bureau ofHealth Professions, Physician Assistant Program Files,ockville, MD, August 1989.

(table 3-1).9It funded 11 rural-focused NP projects

and one rural-focused nurse-midwife project infiscal year 1988. Most of the grantees were family

practice, primary care, or geriatric care NP trainingprograms providing rural clinical experiences andrural-oriented curricula for their students. Of the 208NP training programs operating in 1984, almostone-half received some support from the FederalGovernment (671). The Nurse Anesthetist Trainee-ships grant program10 received $1.1 million in

appropriations in 1990, an increase over 1989appropriations (see table 3-l). The number of rural

programs funded is not known. Examples of Rural-Oriented MLP Training

Programs—NP and PA training programs withrural-oriented curricula have been highly effective inplacing their graduates in rural and underservedcommunities (209,230,337,509,535). Some of theseprograms selectively recruit students who alreadyhave job commitments in the local area once theirtraining is completed. A certificate-level NP training

program at East Carolina University in North

Carolina has been very successful in placing gradu-ates in rural practice (337). A similar program atGeorgia Southern College has also been successful

(see box 13-C). The Primary Care Associate Pro-gram based at Stanford University and FoothillCollege in California trains PAs and NPs to provideservices in medically underserved areas (230). Theprogram has community-based training sites thatrecruit their own students locally and have suc-ceeded in retaining over 70 percent of their graduatesin the local areas (230).

Decentralized education programs have beenhailed as highly effective means of improvingrecruitment and retention of MLPs and other healthprofessionals in rural areas, but the degree of decentralization required has been debated (230).Completely decentralized programs (i.e., those thatprovide all components of the educational process atthe remote site) have higher operating costs thanthose that decentralize only the terminal (or clinical)

phase of training and they may not be any more



program at East Carolina University in North phase of training, and they may not be any more

?Funding is authorizedunderSection 822(a) ofthe Public HealthService Actl~mding iS au~oriz~ Uder Section 831 of the Public Health Service ~t.

Chapter 13--Strategies To Recruit and Retain Rural Health Professionals .341

Box 13-C—Example of a Rural-Oriented Training Program for Nurse Practitioners

Georgia Southern College’s certificate programfor family nurse practitioners (FNPs) emphasizesdevelopment of strong generalist skills and anunderstanding of cultural and health care beliefs of rural populations in southeast Georgia (209). Itprovides rural clinical experience under the supervi-sion of faculty experienced in rural practice. Admis-ions policies favor students living or practicing inrural areas, or who have expressed a commitment topractice in rural areas on completion of the pro-gram. Of the 75 FNPs who graduated from 1981 to1988,74 percent were working in medically under-served rural areas in 1988, providing care topopulations characterized by low income, loweducation, and high mortality rates. A 1985 surveyshowed that over 90 percent of program graduateswere still in Georgia, and 83 percent were employed

as NPs (209,535). This program received Federalgrant funding from 1982-87, without which thecontinuation of the program would have been“highly unlikely” (209,535).

The program has had difficulties recruitingstudents in recent years due to a change in theAmerican Nurses’ Association (ANA) certificationpolicy (209). Beginning in 1992, the ANA willrequire a baccalaureate degree in nursing for NPcertification (263). Not all States require ANA

certification for NP practice, but Georgia does, anda lack of baccalaureate-prepared registered nursesin the area has caused marked decreases in programenrollment (2@+.

effective at retaining graduates in those areas(230).

11

A new barrier to the recruitment of rural nursesinto NP programs is the recent change in AmericanNurses Association (ANA) NP certification policy.The ANA now requires a bachelor’s degree for NPcertification (263). In States that require ANAcertification for NP practice, decentralized trainingprograms that recruit local nurses may not be viabledue to a relative lack of registered nurses (RNs) with

bachelors’ degrees in rural areas (see table 10-43,

box 13-C).

Nurses

Rural experience during basic training may help

to better prepare nurses for general hospital as well

as rural practice. Nursing students participating in

elective rural rotations report that these experiences

are more valuable than those available in urban

facilities because they allow students to practice a

wider range of skills with a greater degree of

independence (482). Nursing students in a rural

hospital preceptorship program who later took

employment at the hospital reported feeling more

comfortable with patients and less overwhelmed by

the orientation process (599).

To make rural nursing more attractive, to improve

retention of nurses who are already in rural areas,

and to improve the rural supply of nurse MLPs (NPs,CNMs, and CRNAs), rural nurses need access to

advanced training programs that will allow them to

upgrade their skills without having to leave their

families or place of employment.

The Federal Government supports general nurse

training through the Advanced Nurse Training,

Nursing Special Projects, and Nursing Demonstra-

tion Project grant programs. None of the grant

programs are entirely dedicated to rural training, but

all fund some rural-focused projects.12

Funding for the Advanced Nurse Training grant

program increased from $12.0 million in 1980 to

$17.3 million in 1988, but it decreased to $12.8

million in 1990 (table 3-1).13In fiscal year 1988, this

program funded three rural-focused projects in

Georgia, North Dakota, and Wyoming (679). These

projects involved rural nurse specialty training

programs and expansion of a master’s level program

in rural nursing. The Nursing Demonstration Project

grant program funded four rural-focused projects in

fiscal year 1988 (679).

Funding for the Nursing Special Projects grant

program decreased from $15.0 million in 1980 to

$12.9 million in 1990 (table 3-1).14This program

for and found post-graduate



ll~e - cue &~~~te fio~ ~ c~or~, for e~ple, mains ~s and P* through both pathways an d has found post graduate U2t(31tiO13

rates among students who took only the terminal phase of training at the satellite center to be even higher than among students who took the entiretyof their training at those sites (230).

12See footnote 8.13Funding is authoriz~ under Section 821 of the Public Health Serviee Act.14Fun@ is authoriz~ Waler Section 820 of the Public Health Servim *t.


funded 39 rural-focused projects in fiscal year 1988

and 40 such projects in fiscal year 1989 (679).Projects included:

continuing education programs for rural nurseson a variety of nursing topics;outreach and off-campus programs to providebaccalaureate degrees to RNs in rural areas;programs to upgrade licensed practical/vocationalnurses (LP/VNs) to RNs;

geriatric, home health, critical care, family,community, and preventive nursing trainingprograms; andnursing preparatory education projects (679).

Some of the special projects used telecommunica-tions to provide nursing education in remote areas(679).

Allied Health Professionals

Rural-oriented training has also been effective inrecruiting allied health professionals (AHPs) to ruralareas. A linkage program between the University of Alabama at Birmingham and several of the States’

junior colleges provides clinical training opportuni-ties for AHP students in underserved sites (91).Students receive their first year of training at a juniorcollege, and the second year at the University of Alabama Medical Center in Birmingham. Their lastweeks of clinical training are completed at smallerhealth care facilities throughout the State (91). After11 years of the program, a study found that 66percent of graduates returned to their home countiesto work (143). Other schools that offer rural trainingopportunities to AHP students include the Univer-sity of Wisconsin Medical Technology program andKentucky Southern Community College (288). Therelatively short length of most AHP training pro-

grams presents an excellent opportunity for localrecruitment of students. The development of decen-tralized training programs such as these appearslikely to improve AHP supply in participatingcommunities.

Rural-oriented training of AHPs with a singleskill, however, will not satisfy the unique staffingneeds of many rural facilities. What are needed are

programs that teach students a broader range of skillsd ff li ibilit f d l lti l tifi ti

primary area of study (e.g., radiography) with the

option to pursue certification eligibility in a secondarea (e.g., medical technology) through an addi-tional year of course work (424). After administra-tors found that many students were not utilizing theirmultiple competencies due to strict departmentallines in hospitals, the program was redesigned tocombine complete competencies in either radiogra-phy or cardiorespiratory care with competencies inemergency medical services/technology, health care

management, gerontology, or computer science(424).

Although demand for multiskilled AHPs is con-siderable (see ch. 10), only a small number of formalcross-training programs are currently in existence(424). A documentation project conducted by theNational Multiskilled Health Practitioner Clearing-house of the University of Alabama at Birmingham

in 1988 identified only 75 programs nationwideoffering multiple competency training. These pro-grams are located primarily in community collegesand 4-year or graduate institutions. The studyidentified only four programs located in hospitals.Programs can be generic, preparing students in twoor more areas of practice, or they can be “add-on”programs that expand the competency of individualsalready certified in one area (424).

Federal funding of AHP training has declinedconsiderably since its peak in the 1970s (table 13-2)(288,674). In 1974, nearly $30 million was awardedin grants, cooperative agreements, and contracts inallied health. In 1986, the figure was zero. Lack of data has prevented assessment of the impact of Federal funding in allied health (288). OBRA 89(Public Law 101-239) approved $750,000 for theAllied Health Special Projects grants program, and$726,000 was appropriated. The program is de-signed to improve allied health program administra-tion and expand enrollments in allied health pro-grams. Only 7 to 10 grants were to be awarded inAugust 1990, but by mid-January 1990, the BHPrhad received almost 1,000 inquiries about theprogram (43).

OBRA 89 also authorized a new grant program

entitled Interdisciplinary Traineeships for RuralA Thi f d d t $2 25 illi i



p g gand offer eligibility for dual or multiple certification.One such program, which was started with the helpof a Federal grant in the early 1970s, is located atSouthern Illinois University at Carbondale. Origi-nally, students in the Carbondale program pursued a

p y pAreas. This program, funded at $2.25 million in1990 (table 3-l), will support interdisciplinaryhealth professions training programs in rural areas,and it could conceivably serve as an additionalsource of support for the training of certain AHPs.


Table 13-2—Federal Grants and Cooperative Agreements Awarded in the Allied Health Area,Fiscal Years 1967-1990

Awards (in millions of dollars)Fiscal Advanced Training Special Special Basicyear traineeships institutes improvements projects improvements Other Total

1967. . . . . . . .1968. . . . . . . .1969. . . . . . . .1970. . . . . . . .1971. . . . . . . .1972. . . . . . . .

1973. . . . . . . .1973a . . . . . . .1974. . . . . . . .1975. . . . . . . .1976. . . . . . . .1977. . . . . . . .1978. . . . . . . .1979. . . . . . . .1980. . . . . . . .1981. . . . . . . .1982. . . . . . .1983. . . . . . . .

1984. . . . . . . .1985. . . . . . . .1986. . . . . . . .1987. . . . . . . .1988. . . . . . . .1989. . . . . . . .1990

d. . . . . . .

0.241.201.551.542.462.59

1.9502.562.612.562.331.441.490.89000

0000000

0

0

0

0

0.480.32

1.1401.000.961.000.640.921.010000

0000000

0

0

0

0

0

10.50

7.0010.50

16.00

10.19

10.508.91

0

0

0

0

0

0

00

0

0

0

0

0

0

0.801.231.234.487.63

5.64010.136.878.208.41

14.358.154.250.5100

0000

0

00.73

3.299.759.759.709.700

000000000000

0000000

0

0

0

0

0

0

00

0

0

0

0

0

00.74

b

0.37 b

o0

0.91

C

0.88C

o000(2.25)

e

3.5311.7512.5312.4717.1321.04

15.7310.5029.6920.6222.2620.2916.7110.655.880.8700

0.910.8800000.73

f

a R e l e a s edimpounded funds.

%ilitary Experience Directed Into Health Careers (MEDIHC) cooperative agreement funds.cGrant- for allied health personnel in health prOmOtion and disease Prevention.

dFigure= represent appropriations and not award amounts. Award amounts were not yet available at the time of

this study.‘Rural Health Interdisciplinary Traineeship grant aPProPriations. Not all of this money will go towards-traineeships in the allied health professions.‘Excludes

SOURCE:

Rural Health Interdisciplinary Traineeship program funds.

Institute of Medicine, Allied Health Services: Avoiding Crises (Washington, DC: National AcademyPress, 1989), table 5-4; U.S. Department of Health and Human Services, Public Health Service, HealthResources and Services Administration, Bureau of Health Professions, Division of Associated andDental Health Professions, Rockville, MD, unpublished data provided by F. Paavola in 1990.

The Area Health Education Centers Federal funding of an individual AHEC may not

(AHEC) Program exceed 9 years (see ch 3). The wide impact and

The AHEC program15

encourages training of success of AHEC-sponsored programs (box 13-D)

health personnel in primary care and emphasizes theindicate that Federal investment in these programs

has encouraged State and local participation inrelationship between educational experiences andhealth care delivery. AHECs provide decentralized activities addressing the geographic maldistribution

clinical education experiences for a variety of health of all varieties of health professionals. Each Project

professional trainees by linking academic resources must contribute at least 25 percent in matching funds

of medical schools with local health facilities and from State or other sources, and some have contrib-

agencies. AHECs also provide confirming education uted considerably more (627,677). Twenty-three

for health professionals in remote communities AHEC programs are now functioning withoutFed-(677} eral funding and 18 more are moving towards



p p g g(677} eral funding, and 18 more are moving towards

IssMch.sforadescnption Of~CprognunaWlmizatim andfml@.

20-810 0 - 90 - 12 QL3


Box 13-D—Selected Area Health Education Center (AHEC) Activities

Arizona: AHECs in Arizona provide rural training experiences for medical residents, nursing students, healtheducators, and other health professions students at clinics serving Arizona’s migrant farmworker population. Healthprofessionals already serving migrant populations also have access to continuing education programs through theAHECs (380).

Arkansas: Programs of the Arkansas AHEC have contributed to improvements in the geographic distributionof physicians in the State. Since 1981, recruitment of family practitioners through AHEC-sponsored residencyprograms has been responsible for the elimination of physician shortages in 9 previously designated shortage areas.Over one-half of the graduates of these residency programs locate in towns of fewer than 20,000 residents (151).

North Carolina: A survey of all physicians who settled in rural North Carolina in 1976,1977, and 1978 found

that activities of North Carolina’s AHEC program had been instrumental in those physicians’ location decisions.The State has experienced dramatic improvements in physician-to-population ratios during the past decade (376).Seventy-three percent of all physicians who participated in a rural-oriented family practice residency programoperated by the Mountain AHEC in Asheville since its inception in 1978 remained within the region to practice(582). Over one-half of these practitioners are located in communities of 10,000 or fewer residents (582) . The AHEChas also been involved in developing off-campus baccalaureate programs for registered nurses, clinical training sitesfor both undergraduate and graduate nursing students, and continuing education opportunities for nurses and otherhealth professionals in rural areas (101).

Oklahoma: The Oklahoma AHEC program provides preceptorship opportunities at Indian Health Service

clinic sites and tribally operated clinics and hospitals for a variety of health professions students (231).South Carolina: An AHEC in rural South Carolina coordinates with educational directors in hospitals

throughout the region to determine the continuing educational needs of hospital employees. programs to addressidentified needs are conducted at the facilities demonstrating greatest need, or at central locations where healthprofessionals from all facilities attend. The AHEC program also serves the continuing education needs of nonhospital-based pharmacists, dietitians, nutritionists, nurses, and emergency medical personnel within the region(729).

Texas: AHECs in Texas are creating telecommunication linkages between health science centers and smallrural hospitals for consultation and patient referral. The health science center provides the hardware, and the AHECprovides the health care specialists and information sources required to meet the needs of participating institutions.Other cooperative projects of the AHEC include joint pharmaceutical and supply purchasing, emergency transportinformation, and shared provider services (170).

Virginia: The Western Tidewater AHEC on Virginia’s Eastern Shore provides multidisciplinary experiencesin health promotion/disease prevention among migrant farm worker populations for students in dentistry, dentalhygiene, medical technology, nursing, and medicine (712).

WAMI: The WAMI/AHEC program (serving the States of Washington, Alaska, Montana and Idaho throughthe University of Washington School of Medicine in Seattle) operates a Rural Hospital Project funded by the W.K.Kellogg Foundation. Its purpose is to examine the plight of rural hospitals within the region. This project representsan expansion beyond the typical AHEC program goals, involving administrative, planning, and policy personnel

in addition to health care practitioners (44).

.

independence (table 13-3) (677). The first genera- AHECs may cover portions or all of a State. Whiletion of AHECs (table 13-3), although intended as partial-State AHECs may be rural or urban, State-multidisciplinary efforts, devoted the greater portionof their resources to physician education (210). Inthe second and third generations, and in the continu-

ing activities of first generation projects, a greateremphasis has been placed on nonphysician educa

wide AHECs can encompass both rural and urbanprojects. Figure 13-1 depicts the distribution of thevarious types of AHECs across the country (677).

.

AHECs are involved in a wide variety of educa-tional and service activities ranging from rural



emphasis has been placed on nonphysician educa-tional interventions (210). Federal funding for AHECshas remained relatively stable during the past decade(table 13-4) (677).

tional and service activities, ranging from ruralclinical experiences for health professions studentsto research on the financial viability of ruralhospitals (box 13-D). AHECs in Arizona, New




Table 13-4-Federal Funding of the Area Health

Education Centers (AHEC) Program, Fiscal Years1978-1990; and Impact of the AHEC Programs,Fiscal Year 1988

Appropriationa

Fiscal year (in $ millions)

1978 . . . . . . . . . . . . . . . . . . . .1979. . . . . . . . . . . . . . . . . . . .1980. . . . . . . . . . . . . . . . . . . .1981. ....;.... . . . . . . . . . .

1982. . . . . . . . . . . . . . . . . . . .1983. . . . . . . . . . . . . . . . . . . .1984 . . . . . . . . . . . . . . . . . . . .1985. . . . . . . . . . . . . . . . . . . .1986. . . . . . . . . . . . . . . . . . . .

1987. . . . . . . . . . . . . . . . . . . .1988. . . . . . . . . . . . . . . . . . . .1989. . . . . . . . . . . . . . . . . . . .1990. . . . . . . . . . . . . . . . . . . .

$17.0

20.0

21.0

21.0

18.217.9

17.9

18.0

17.2

18.0

18.0

16.9

18.5b

Funding and impact, fiscal year 1988

AHEC programs (Sec. 781(a)(l))

Amount awarded. . . . . . . . . . . . . . . . . $15.5 million Number of projects . . . . . . . . . . . . . 18Number of regional centers. . . . . 43

Number of States served . . . . . . . . 21

Special initiativesc

(Sec. 781(a)(2))

Amount awarded. . . . . . . . . . . . . . . . . $1.7 million

Number of projects. . . . . . . . . . . . . 28

Number of States served . . . . . . . . 10

a$87.9 million were awarded as contracts under the

HMEIA authority from 1972 through 1976.

bA separate but similar program, the Health Education

Training Centers Program, was authorized in 1988

(Public Law 100-607) and was appropriated $4.0million in 1990. The program focuses on the train-

ing of health professionals in areas along the

U.S.-Mexico border. The $18.5 million AHEC approp-

riation here is exclusive of that $4.0 million.c

See ch. 3 for an explanation of AHEC special init-

iative funding.


vices, Health Resources and Services Admi-

nistration, Bureau of Health Professions,Division of Medicine, “The Area Health

Education Centers Program: Town and Gown

Working Together to Improve the Nation’s

Health,” app. II, Rockville, MD, 1988. Up-

dated by OTA.

Mexico and Texas emphasize recruitment of healthprofessionals to serve Hispanic communities (677).

Other AHECs focus on training of health profession-

als to serve Native American and black populations.AHECs operated through Meharry Medical College,

ing sites (677). An AHEC in Washington State has

established an office of rural health that engages innumerous research and service activities relating tothe States’ rural health care needs (426).

The goals and priorities of AHECs differ depend-ing on their geographic location. While urbanAHECs concentrate on graduate medical education,health professions career opportunity programs,health education and nutrition programs, and under-graduate medical education, rural AHECs tend toemphasize nursing education and continuing profes-sional education (210). Rural AHECs also havedevoted a substantial portion of their resources toproviding support for area National Health ServiceCorps (NHSC) providers and career mobility fornurses (210). A recent national study found thatnonmetro counties with AHECs--especially coun-ties not adjacent to metro counties-had greatergrowth in primary care physician supply between1975 and 1985 than counties without AHECs (281).

Although response to local needs undoubtedlydictates some of the differences between rural andurban AHECs, differences in opportunities to con-duct certain types of training programs may beanother important factor. For example, comparedwith urban AHECs, rural AHECs may allocate fewerresources to undergraduate medical education pro-

grams because they are more remote from medicalschools and have fewer local resources (210). Also,rural communities may not consider student trainingprograms as important as the need for trained

physicians in the area, especially if there is noguarantee that these students will return to the areato practice (210).

STRATEGIES TO REDUCE

PROFESSIONAL ISOLATION

Consultative and Educational Opportunities

Through Telecommunications

One means of increasing the professional re-sources available to rural practitioners is improve-ment of telecommunications networks, throughwhich health professionals have access to consult-

ants, literature databases, new technologies, andcontinuing education programs.



p g y g ,Morehouse School of Medicine, and Charles R.Drew University have demonstrated success withincreasing the number of black health professions

students in the AHECs’ underserved clinical train-

The KARENET system, operated by Texas TechUniversity’s Health Sciences Center, places a com-puter terminal by each patient bed in participatingrural hospitals, enabling direct consultative contact


Figure 13-l—Distribution of Area Health Education Center (AHEC) Programsby State, 1988

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureauof Health Professions, Division of Medieine, “The Area Health Education Centers Program: Town and Govvn

Working Together to Improve The Nation’s Health,” Roekville, MD, 1988.

with specialists at the Health Sciences Center inLubbock (268).

16Another project, MEDNET, will

be a two-way interactive video network linkingTexas Tech specialists to rural physicians. The useof these programs is expected to decrease travelingtime for patients and health providers, as well asimprove occupancy rates in rural hospitals that

would otherwise be obliged to refer problem cases tothe Health Sciences Center (268).

Teleconference networks, such as the South

Dakota Medical Information Exchange (SDMIX),

established in 1981 at the University of SouthDakota at Sioux Falls, are capable of reachinghundreds of people across hundreds of miles atrelatively low cost (259). Strictly an audio system,SDMIX offers a series of l-hour continuing medicaleducation programs for physicians and additionalprogramming for medical support staff. Unlike someteleconference networks SDMIX is not a fixed

telephone, no matter how distant. Users at up to 57sites can participate simultaneously (259).

A recent initiative at the National Library of Medicine (NLM) focuses on making NLM productsand services available to health professionals inisolated rural and inner city areas (422). The NLM’sRegional Medical Library Program is a computer-accessed network of nearly 3,000 medical librariesserving all 50 States. Libraries participating in the

network have agreed to provide services to helphealth professionals identify, locate, and obtaininformation (422).

Health professionals in rural areas, however, maynot have ready access to computers and telephonelines that enable them to use the service (422).Purchase of required hardware (e.g., computers,satellite sending and receiving equipment) may alsobe a major barrier to utilization of telecommunica-tions technology, particularly for solo providers inisolated rural areas (Some people have suggested



teleconference networks, SDMIX is not a fixednetwork and thus can accommodate any site with a

isolated rural areas. (Some people have suggestedthird-party reimbursement for patient care-related

16~e ~rop ~m ~d~ by tie TV.K. Kellogg Fou.ndstioq an d hardware was provided by A’rA’r.


telecommunications costs (83).) Other disadvan-tages of telecommunications technologies are theirlevel of complexity and the training they mayrequire on the part of physicians and other users.NLM has recommended additional funding for aprogram that would bring individual health profes-sionals into the network, as well as for expansion of a grant program that would bring NLM’s productsand services to a larger number of isolated medicalfacilities (422).

Opportunities for Vacation and Educational Leave

Some rural health professionals may be unable totake professional or personal leave because there isno one to replace them while they are absent. The“burnout” problem may be particularly severe forsolo practitioners in isolated rural areas who are oncall continuously. To address this problem, some

States have developed special locum tenems servicesto provide relief for rural practitioners. For example,a Robert Wood Johnson Foundation-tided projectin Montana is developing a registry of providersavailable for temporary placement in rural Montanacommunities (126).

Satellite clinic networks and physician-midlevelteam practices can also help to reduce professionalisolation. These strategies are discussed later in this

chapter.

FEDERAL STRATEGIES TO

ADDRESS ECONOMIC

CONCERNS

The Federal Government has taken steps toincrease Medicare payments to primary care andrural physicians. Other strategies to address eco-nomic concerns of rural practice<. g., Federal andState educational loan repayment programs andother private sector efforts-are discussed later inthis chapter.

The Resource-Based Relative Value Scale

(RBRVS)

A number of statutory changes in Medicare

payment to physicians have been aimed at increas-

ing payment to primary care providers at the expense

of payment for secondary care services. OBRA 87(public Law 100-203) introduced a number of incremental changes that included:

q

q

q

permitting maximum annual increases in physi-cians’ charges to Medicare to be higher for

primary care services than for other services,setting minimum levels for prevailing chargesfor primary care services,

17and

authorizing bonuses above and beyond what

Medicare ‘would normally pay for-

physicianservices delivered in designated Health Man-power Shortage Areas (HMSAs) (see below).

OBRA 89 (Public Law 101-239) introduced moregeneral payment reforms to further increase pay-ment for primary care services. This law establisheda resource-based relative value scale (RBRVS) asthe basis for Medicare physician payments as of January 1, 1992, to be phased in fully by 1996.Under the RBRVS, differences in payment amongdifferent types of physician specialists for the sameservice will be eliminated gradually over time, anda higher relative value than in the past will be placedon ‘‘evaluative and management services’ ’-thetypes of services most often performed by primarycare physicians (475). Unlike the current system,which bases payments on ‘‘customary, prevailing,and reasonable’ charges for specific services withinspecified prevailing charge localities (see chs. 3 and12), payments under the new system will bedetermined by a relative value scale that is based onthree components: work, practice expenses, andmalpractice expenses. Geographic adjustments

18

will be applied fully to practice expenses andmalpractice, but only to one-fourth of the work component (which represents approximately 60percent of each fee) (475).

Detailed projections of the impact of the RBRVSon physicians and beneficiaries cannot be made atthis point because the new fee schedule has not yetbeen developed. The Physician Payment ReviewCommission (PPRC) predicts that rural physicianswill fare well under the new plan because they aremostly primary care physicians, and because thegeographic cost of living adjustment will only apply

to one-fourth of the work component (475).

i h M di



17For most services, the Medicare fee is det ermined according to the prevailing charge for a particular service within a given locality. Under thislegislatio~ however, the minimum allowable payment for primary care services is based on 50 percent of the national average prevailing charge,regardless of the local prevailing charge.

18&OWap~c ad jus~en t s lower pa~ents in areas with lower ~Sts Of ~ving.


Table 13-5-Changes in Physicians’ Medicare andTotal Revenues Under Medicare’s Resource-Based

Relative Value Scale (RBRVS), by Specialtya

Table 13-6-Change in Medicare Payments UnderMedicare’s Resource-Based Relative Value Scale

(RBRVS) in Metropolitan and Nonmetropolitan Areasa

Percent change in

Practice revenues from:

Specialty Medicareb

All sourcesc

Medical

Internal medicine. . . . . . . 17 4

Family practice. . . . . . . . . 38 6

Dermatology. . . . . . . . . . . . . 1 NA

SurgicalOphthalmology. . . . . . . . . . . -16 -8General surgery . . . . . . . . . -lo -5Orthopedic surgery . . . . . . -7 -3Urology . . . . . . . . . . . . . . . . . -5 NA

Thoracic surgery . . . . . . . . -20 - 9

Otolaryngology. . . . . . . . . . 6 NAObstetrics/gynecology. . . 2 0

Hospital-based

Radiology. . . . . . . . . . . . . . . -21 -7

Pathology. . . . . . . . . . . . . . .-?

5 NA

NOTE: NA = not available.aThese estimates are based on an earlier version of RB/RVS and do not reflect the effect of the

geographic cost of living adjustment which will

apply to 25 percent of the work component under the

version adopted in Public Law 101-239.bMedicare Progrm payments are exclusive of balance

bills (see text).cIncludes revenues from all payers. RBRVS onlY

applied to Medicare revenues. Medicare assignment

rates are assumed to be unaffected by the new RBRVS

fee schedule and 100 percent of balance bills (at120 percent of the prevailing charge) are assumed

to be collected. Estimates of non-Medicare revenues

are unavailable for some specialties.

SOURCE: Physician Payment Review Commission, Annual

Report to Congress, 1989 (Washington, DC:

PPRC, 1989), table 9-8.

Based on a simulated model, PPRC predicted thatunder the new system, specialties that will receive

the greatest increases are those that engage in agreater proportion of "evaluative and management”as opposed to “procedural” services--e.g., familypractice and internal medicine (table 13-5) (475).Surgical and hospital-based specialties (e.g.,oph-thalmology, radiology, and pathology) will lose themost. Within specialties, the impact of the new feeschedule will depend on the proportion of evaluativeand management services performed (475).

Changes in overall Medicare reimbursement toh i i ill b bl b i l h i

Specialty PercentArea

bgroup change

a

Metro county-----------------------------------------------------

3,000,000+ population Medical 10Surgical -15

All physicians-4

1,000,000 to 3,000,000 Medical 14Surgical -14

All physicians -5

Fewer than 1,000,000 Medical 2Surgical -9

All physicians 1

Nonmetro county-----------------------------------------------------

25,000+ population Medical 28

Surgical -5

All physicians 12

Fewer than 25,000

Medical 34

S u rg ica l - 8

All physicians 13

a

Estimated changes reflect the difference between

average 1988 charges (under reasonable charge payment) and fee schedule charges under the version

of RBRVS adopted in 1989 (Public Law 101-239). bMetro and nonmetro counties accounted for 84 and 16

percent (respectively) of Medicare allowed amountsin 1988.

SOURCE: Physician Payment Review Commission, AnnualReport to Congress, 1990 (Washington, DC:PPRC, 1990), table 2-3.

the largest urban areas; medical specialists in ruralareas will have the greatest increases (table 13-6)

(475).

Restrictions on balance billing will go into effect

before the new fee schedule. “Balance billing”isthe difference between what Medicare will pay (the“allowed charge’’) and what the physician actuallycharges the patient (the “billed charge’’). Under the1989 1egislation, no physician will be permitted to

charge beneficiaries more than 115 percent of theMedicare allowed charge. The full restriction willl b i i i 1991 t h i i h h d



physicians will probably be greater in rural than inurban areas, with the greatest increases in thesmallest rural areas (475). Medical specialties as agroup will increase their Medicare income in all but

apply beginning in 1991 to physicians who chargedwithin this limit in 1990, but it will be phased inmore gradually for physicians who charged outsidethe limit in 1990 (limits will be 125 percent in 1991,






Other strategies for addressing the needs of

remote communities include increased use of MLPsand satellite clinics.

The National Health Service Corps

The NHSC has been the single most direct Federalprogram addressing health personnel distributionduring the last two decades. Since 1971 it has placedover 16,500 health professionals

28in federally

designated HMSAs (663). The genesis of the pro-

gram was the Emergency Health Personnel Act of 1970 (Public Law 91-623), which authorized theSecretary of the Department of Health, Education,and Welfare (DHEW) to assign commissionedofficers in the Public Health Service in areasdesignated as having critical shortages of healthmanpower and services. In 1971, 20 physicians inthe Public Health Service Commissioned Corpslocated in these areas. To expand this small corps of

health professionals, Congress authorized a scholar-ship program in 1972 (Public Law 92-585) thatobligated professionals to similar service. In 1987, asmall authorization was made available for two loanrepayment programs: one administered by the Fed-eral Government, and the other administered by theStates. In 1988, funding for the scholarship programwas largely discontinued,

29and a Volunteer Pro-

gram was established to recruit non-obligated health

professionals to HMSAs.

Sources of NHSC Personnel

The Scholarship Program—The NHSC Scholar-ship Program was first funded in 1974 at a level of $3 million (table 13-7) (618). Funding peaked at$79.5 million in 1980, with over 6,000 new orcontinuing scholarships, and then decreased steadilyuntil 1989, when no new funds were appropriated.

Scholarship recipients undergo an average of 6 yearsof education before they are available to serve (346);consequently, the peak number of professionalsserving their obligation occurred in 1986 (table13-7) (618). Over 13,000 students have been awardedscholarships under this program, and approximately10,400 eventually served (or are serving) theirobligation in the field (689). Some 70 percent of

these served in “rural” areas (including those in

Indian Health Service sites), and 30 percent servedin “urban” areas (689).

30

The overwhelming majority of scholarships wereawarded to medical students (both allopathic andosteopathic); the rest went to students in a variety of other health professions (including dentistry, nurs-ing, pharmacy, optometry, and veterinary medicine)(662). Students could qualify for up to 4 years of scholarship if they indicated an interest in primarycare and promised to serve 1 year in a federallydesignated HMSA for each year of scholarshipreceived, with a minimum 2-year service obligation.Payback began when students had completed theirtraining, although some physicians opted to servebefore or during specialty training (662). As of January 1990, 80 percent of scholarship recipientshad served or were serving their obligation, 16percent had repaid their scholarship awards,

31and 4

percent had defaulted (346). The default rate isexpected to decline with a new amnesty program,which permits defaulters to pay back their obligationthrough service (662).

The Loan Repayment Program—1987 legisla-tion (Public Law 100-177) authorized the creation of two programs through which the Federal Govern-ment would subsidize the repayment of educational

loans health professionals in return for service indesignated HMSAs.

The Federal Loan Repayment Program recruitsproviders and repays their loans at a rate of up to$20,000 a year if they provide primary care healthservices in a qualifying HMSA (661). Participantsmust serve from 2 to 4 years (661). The programplaced 132 participants in 1988 and 1989 (table13-7) (659).

The State component of the program providesFederal monies to States for the repayment of healthprofessionals’ student loans. States must cover alladministrative costs, and they must provide at least25 percent of total loan repayment funds (661).Qualifying areas for State loan repayment place-ments are determined by the individual States,

~As of r)ece~r 31, 1989, th e total number of health professionals placed through theNHSC skw the be- ef the program was 16,560. Thisincludes all health professions disciplines and all recruitment categories (i.e., volunteer, obligated, and commissioned corps) (663).

~A smau amount of monv was available for scholarships in fiscal year 1989 due torepmgrm of certain Ioanrepayment funds (see table 13-7).



p y ( )

me NHSC defines “rural” as nonurbanized areas, some of which are located within metro counties (1).

31~the ~ly ~w50f t h e p ro = schol~h, ipr~ipients who did no t s~ e ~~sAs~d to repay thepficip~plus intwes~ hlkteryears, the P6Xlil@

was increased to triple the principal plus interest (689),

Table 13-7—National Health Service Corps: Funding and Participants in Field, Scholarship, and Loan Repayment Programs,Fiscal Years 1971-89

Field Programa

Scholarship Programb

Loan Repayment Program c

Appropriation Year-end Appropriation Awards Appropriation

Fiscal year ($ thousands) field strengthd

($ thousands) New Continuation Total ($ thousands) Awards

1971. . . . . . . . . . . . $3,000 20 NA NA NA NA NA NA

1972. . . . . . . . . . . . 12,574 181 NA NA NA NA NA NA

1973. . . . . . . . . . . . 11,000 330 NA NA NA NA NA

1974. . . . . . . . . . . . 9,787 405 $3,000 372 0 372 NA NA

1975. . . . . . . . . . . . 14,055 488 22,500 1,499 365 1,864 NA NA

1976. . . . . . . . . . . . 28,662 600 22,500 1,759 3,442 5,201 NA NA

1977. . . . . . . . . . . . 24,354 690 40,000 2,092 1,481 3,573 NA NA

1978. . . . . . . . . . . . 39,696 1,425 60,000 3,150 1,907 5,057 NA NA

1979. . . . . . . . . . . . 62,969 1,826 75,000 2,380 4,029 6,409 NA NA

1980. . . . . . . . . . . . 74,075 2,080 79,500 1,772 4,387 6,159 NA NA

1981. . . . . . . . . . . . 84,739 2,338 63,400 162 4,175 4,337 NA NA

1982. . . . . . . . . . . . 95,078 2,782 42,500 160e

2,289 2,449 NA NA

1983. . . . . . . . . . . . 93,391 2,865 15,458 144e

793 937 NA NA

1984. . . . . . . . . . . . 91,000 2,609 6,300 69e

98 167 NA NA

1985. . . . . . . . . . . . 75,000 2,958 2,300 37e

12 49 NA NA

1986. . . . . . . . . . . . 58,500 3,304 2,201 36e

7 43 NA NA

1987. . . . . . . . . . . . 39,884 2,742 2,300 46e

3 49 NA NA

1988. . . . . . . . . . . . 37,442 2,097 2,202 36e 4 40 915 20

1989. . . . . . . . . . . . 39,866 l,948f

2,953g

43e

6 49 3,953 112


aTheNHSC fle~d budget funds th e salaries of federally employed assignees, the travel costs of new and current assignees, various

clinical support activities, technical assistance to States, and recruitment and retention activities of the program. From 1971

through 1978, all.NHSC field placements were NHSC-salaried. Since 1979, there has been a trend away from NHSC-salaried positions and

towards other types of placement. From 1983 through 1988, portions of the original NHSC Field Program appropriations were reprogrammed

into the budget for Comnunity and Migrant Health Centers to help pay the salaries of NHSC assignees in those centers. Field Programappropriations in this table exclude reprogrammed amounts.

bThe NHSC scholarship Progrm provided scholarships to health professions students in exchange for service in a designated ‘hortage area

when they completed their training. The minimum service obligation was 2 years, and the majority of scholarships went to medical

students.cF1gures in this table refer only to the Federal Loan Repayment progr~.dThe number of NHSC personnel in the field at the end of the calendar Year. Includes personnel in all

volunteer and obligated, in both NHSC and IHS sites.eMultiyear awards.

fThis figure was ~oted over the telephone by NHSC staff in January lggo.

gReprogrmed from State loan repayment funding for 198g. Originally, no funding was appropriated for newsince only 1 million of the 3.9 million appropriation for the State Loan Repayment Program was used in 1989,award 43 new scholarships for exceptionally financially needy medical students.

health disciplines, both

scholarships in 1989, but

the remainder was used to

OURCES: U.S. Congress, Office of Technology Assessment, Clinical Staffing in the Indian Health Service, Special Report (Washington,

DC: OTA, February 1987); U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureauof Health Care Delivery and Assistance, unpublished data provided by G. Goubeau, Nov. 9, 1989.






Table 13-9-Federally Salarieda Personnel in the

National Health Service Corps (NHSC) byObligation Status, 1989

Table 13-10-National Health Service Corps Providers

by Discipline, 1981 and 1989

a

Obligation Status

Nonobligated b

Employment Scholarship or loanstatus obligors repayment Total

Commissioned corps. . . 20 118 138

Civil service. . . . . . . . 124 16 140

Total . . . . . . . . . . . . . . 144 134 278

apersonnel in the NHSC who receive their salaries

directly from the NHSC.bInclude~ some scholarship recipients who comPleted

their service obligation but decided to stay on inthe NHSC consnissioned corps.


vices, Health Resources and Services

Administration, Bureau of Health Care

Delivery and Assistance, Division ofNational Health Service Corps, unpublished

data provided to OTA Jan. 24, 1990.

Commissioned Officers in the NHSC--Com-missioned officers in the NHSC are a subset of thePublic Health Service (PHS) Commissioned Corps.They are a mobile cadre of health professionals whoreceive their salaries directly from the NHSC and aredeployed in high priority HMSAs. NHSC scholar-ship or loan repayment recipients as well as nonobli-

gated volunteers can choose to join the NHSCCommissioned Corps if positions are available. Likeother PHS Commissioned Corps personnel, how-ever, they are subject to periodic transfer from onesite of service to another.

As funding for the NHSC Field Program hasdecreased, so have the number and proportion of NHSC commissioned officers and other NHSC-salaried personnel.

34While commissioned officers

once represented the majority of field staff, they nowmakeup only a small percentage. of the 1,948 totalfield staff in 1989 (table 13-7) (6.59), only 278(14percent) received their salaries through the NHSC(table 13-9) (663). Of these 278, approximatelyone-half were commissioned officers and the re-mainder were civilian employees (table 13-9)(663).

Placement of NHSC Personnel:The Field Program

The NHSC Field Program places personnel from

Provider Fiscal yeardiscipline 1981 1989

Physicians. . . . . . . . . . . . . . . . . 7,272 2,187

General practice . . . . . . . . 1,098 84

Family practice. . . . . . . . . 2,038 614

Internal medicine . . . . . . . 2,088 671

Pediatrics. . . . . . . . . . . . . . 968 286

Obstetrics/gynecology. . . 454 242

Psychiatry. . . . . . . . . . . . . . 417 215Other . . . . . . . . . . . . . . . . . . . 209 75

Dentists . . . . . . . . . . . . . . . . . . . 957 98

Nurse practitioners. . . . . . . . 319 17

Physician assistants. . . . . . . 111 0

Nurse-midwives. . . . . . . . . . . . . 68 1Podiatrists. . . . . . . . . . . . . . . . 111 27Other . . . . . . . . . . . . . . . . . . . . . . 319 17

Total . . . . . . . . . . . . . . . . . . . . 9,157 2,347

aNumbers in this table differ from year-end field

strength numbers in table 13-7 because they reflectthe number of providers serving at any time from Oct. 1, 1980 to Sept. 30, 1981 or from Oct. 1, 1988to Sept. 30, 1989 rather than the number of

providers present in the field at the end of thecalendar year. Numbers include both obligated andnonobligated providers.


vices, Health Resources and Services Admin-

istration, Bureau of Health Care Delivery

and Assistance, Division of National Health

Service Corps, unpublished data provided to

OTA Feb. 7, 1990.

grams in qualifying sites. The majority of fieldplacements have been and continue to be physicians(table 13-10) (663). MLPs (nurse-midwives, NPs,and PAs) represented a significant proportion of thetotal field staff in 1981, but their numbers havedropped to almost zero (table 13-10) (663). The

number of dentists as a proportion of all NHSCproviders has also decreased (table 13-10)(663).

The four basic mechanisms used to place NHSCpersonnel are:

q Federally Salaried—providers receive theirsalaries directly from the NHSC;

q Private Practice Assignment (“PPA”)--providers are salaried through facilities thathave Federal grant money (from non-NHSC



scholarship, loan repayment, and volunteer pro-g y

sources) dedicated for that purpose (e.g., fed-

~Inadditionto~SCco~ssioned officers, sornecivilian~sc personnel also receive theirsakuies directlyfiornthe~sc.


q

q

erally funded Community and Migrant Health

Centers); Private Practice Salary-providers are sala-ried through projects or facilities that do not

have Federal grant money dedicated for thatpurpose, but who are located in qualifyingareas;

Private Practice Option (“PPO’’)--providersset up their own private practice in an HMSA,without any financial assistance from the Fed-

eral Government (662).35

Until 1979, the year in which the first large groupof scholars came out of the ‘‘pipeline,” the majorityof field placements were volunteers or commis-sioned officers (662). In 1979, the field strengthmore than doubled due to the addition of obligatedscholars. It peaked in 1986, with 3,304 NHSCpersonnel

36practicing throughout the United States.

Field strength decreased by 36 percent from 1986 to

1988 (table 13-7) (618,659), and it will continue todecrease as the “pipeline” dries up and currentpersonnel complete their service obligations. NHSCField Program funding has declined dramaticallysince its peak in 1983 (table 13-7) (618,659). Thenumber of HMSA designations and the number of physicians needed to remove these designations,however, have remained relatively stable during thistime (see ch. 11).

Problems and Changes Over Timein NHSC Programs

Over the years, changing needs of underservedcommunities, changing preferences of health profes-sionals, and reductions in the NHSC budget havecaused the NHSC to adapt its recruitment andplacement strategies.

Sources of NHSC Personnel—To earn scholar-ships, students make commitments from 4 to 8 years(the average has been 6 years) before they are due toserve (346). However, during the course of theirstudies many factors (family characteristics, careerinterests, etc.) can change their ultimate specialtyand location preferences. In some cases, NHSCscholarship recipients changed their primary carepreference to nonprimary care specialties (662),

undermining chances that communities with small

service populations would be able to retain them

beyond their period of obligated service.Part of the rationale behind the transition to loan

repayment was that commitments near the end of training would prove more valid than early commit-ments as indicators of enduring interest in primarycare and practice in an undeserved community(689). In addition, a loan repayment program wouldrecruit personnel to the field immediately, while ascholarship program has along ‘‘pipeline’ betweenreceipt of scholarship and start of service. Moreover,since potential loan repayment participants would beaware of the specific placement opportunities availa-ble before signing a contract, they might make moreinformed decisions and be less likely to “default”on their obligations (689).

Loan repayment and scholarship programs mayattract different types of providers (689). Physicians

and other health professionals with high educationaldebts may find NHSC loan repayment an attractiveincentive. Scholarship programs may be more effec-tive for recruiting nurses, MLPs, and allied healthprofessionals because their educational costs andassociated debts are lower than those of physicians.The NHSC Scholarship Program also attracted manyminority and disadvantaged students who otherwisemight not have been able to afford medical school.

Of scholarship recipients who completed theirobligations and for whom data are available, 17percent were black, and 9 percent were from otherminority groups (689).

Although the Federal Loan Repayment Programgave priority to NPs and CNMs j 115 of the total 132placements in 1988 and 1989 were physicians,because few CNMs and NPs had applied (662).Although one explanation for their lower applicationrate is the lower debt burden of CNMs and NPs, 37 itis likely that lack of information was also a majorreason for the lack of candidates. It has been reportedthat over one-half of CNM training program direc-tors had not heard of the program as of fall 1989(191).

The State Loan Repayment Program was intendedto improve recruitment by decentralizing efforts and

encouraging State investment in loan repayment

35Tw~c~ ~5~5~ce in site development and practiw management is provided through regional and State NHSC offices.i i d d h lth f i l



36~e ‘~yem.end field s~a@~~ ~olu ~ @ble 13.7 fi~ludes commissioned and Obfigated MSC field s@fin d health professional fiekk.

37some Contmd ti t ~~, bame thek professio~ ~mme is co~idembly lower tin tit of physic~s , my fmd loan repayment ~ iWEiCtiVe

incentive even with relatively smaU debt burdens (191).


activities. The 25 percent matching requirement,

however, may dissuade some of the neediest Statesfrom applying. This concern, as well as others withinBHCDA about the success of the program during itsfirst year, prevented the planned expansion of theprogram in its second year.

In fiscal year 1989, BHCDA officials requestedcongressional permission to redirect $2.9 millionoriginally appropriated for new State Loan Repay-

ment programs to Federal NHSC scholarships (224).During the first year of the program, the originalseven State grantees had difficulty finding sufficientnumbers of participants to use awarded funds (689).According to State grantees, however, BHCDA hadgiven them insufficient time in which to recruitparticipants and make awards. States were notifiedabout the program in September of 1988, and theyhad only 1 month to identify qualifying health

professionals.

38

Inability to use funds for repaymentof undergraduate loans, a low maximum allowableyearly repayment rate, and a lack of candidates withsufficient levels of debt have also been cited aspossible reasons for States’ limited success duringthe first year (689).

The new NHSC Volunteer Program has suc-ceeded in attracting a significant number of person-nel since its inception in 1988, but it might have a

greater impact if additional incentives were availa-ble to practitioners serving in HMSAs. As of 1991,physicians locating in rural primary care HMSAswill be eligible for a 10 percent bonus on Medicarereimbursement (Public Law 101-239). Additionalincentives might include reimbursement for travelfor practitioners and spouses making site selectionvisits, and tax breaks or lump-sum bonuses forhealth personnel who practice in HMSAs. Volunteerrecruitment is also hampered by a lack of recruitingstaff in the Federal and regional offices (662).

Methods of Placing NHSC Personnel—Mostfield placements were NHSC-salaried up until 1979,but thereafter a shift toward other salary sourcesoccurred (224). In 1988, only 15 percent of NHSCfield positions (excluding those at Indian HealthService sites) were NHSC-salaried; 54 percent were

PPA; 23 percent were private practice salary; and 8

percent were PPO (659). The changing pattern of

salary and placement mechanisms reflects a varietyof concerns.

In the early 1980s, policymakers supported theuse of the PPO as a way of reducing the Federalfinancial burden accruing from the growing numberof obligated scholars emerging from the pipeline.However, in the mid-1980s, the NHSC reduced thenumber of PPO placements in response to concerns

about the short-term and long-term viability of independent private practices in small, remote com-munities (662).

The NHSC had once also held that the PPO wouldimprove retention by increasing physicians’ per-sonal investment in a location (78), a position whichhas since been questioned. Originally, PPO obligorswere only permitted to locate in areas with econo-

mies sufficient to sustain a private practice, but thisrequirement was eliminated in the Health ProgramsExtension Act of 1980 (Public Law 96-538), pre-sumably to allow PPOs to fill the gaps left by thedecreasing number of NHSC-salaried physicians.Faced with drastic decreases in funding for theNHSC field program, scholarship graduates weresometimes told that the PPO was their only optionshort of triple-indemnity repayment or default (78).

(Practice management and other technical assistancewere presumably available through a State contrac-tor’s office or through the regional office, but thedegree of support from these offices may have variedgreatly.)

During the 1980s, use of the private practiceassignment (PPA) increased in response to thegrowing need for physicians and other health

personnel in federally funded community and mi-grant health centers (C/MHCs), as well as to thesame budgetary concerns that inspired the increaseduse of the PPO placement (662).

39The shift to PPA

placements also reflected concerns raised by experi-ence with the PPO. The NHSC had come to believethat placing personnel within structured systems of care was more stable than placing them in solopractice in communities unable to support such

practices (662).

3S~ormation on specific State programs was gained through telephone convemations with program administrators.f Fi ld i ti



3g’Jo cover tie s-es of tie ~~ n-r of PpA W~oMel, Substantial portions of tie orie ~SC Field Program appropriations werereprogrammed into the budget for C/MHCs from 1983 through 1988 (224). For example, in 1987, $15.5 million were reprogmmmed to C/MHCs.NHSC-salaried personnel are present in some C/MHCs, but the majority of NHSC personnel in these facilities are PPA. Some C/MHCs are not indesignated HMSAS, but maybe approved for NHSC obligated personnel placement if they demonstrate sufllcient need (662).


As a result, C/MHCs have come to depend heavily

on the NHSC for physicians. PPAs accounted formore than one-half of all NHSC placements in 1988(659), and obligated NHSC physicians accountedfor over one-half of all physicians in C/MHCs in1989 (411,414). Even within the more structuredPPA settings, however, retention of NHSC person-nel is a problem. Financial constraints prevent PPAsponsors from offering salaries competitive withthose in the private sector; consequently, PPAs often

leave C/MHCs once their periods of obligation end(414).

The Changing Role of Commissioned Officersin the NHSC—In the late 1970s and early 1980s,physicians whose obligations were ending were toldthey could remain on salary in their communities if they joined the NHSC as commissioned officers, anda number of them did so (662). In 1985, however, thePublic Health Service (PHS), as part of a general

effort to revitalize its Commissioned Corps, reas-signed all commissioned officers, including those inthe NHSC (662). Many opted to leave the Corpswhen asked to move (78). This reaction brought tolight what might be an inherent contradictionbetween the goals of the NHSC and the PHSCommissioned Corps. While the major goal of theNHSC is to recruit and retain health professionals inareas of need, the goal of the PHS Commissioned

Corps is to maintain a mobile cadre of healthprofessionals who can be transferred as needed.Some critics have proposed that the PHS waive thetransfer requirement for NHSC commissioned offi-cers currently serving in remote, high-need areas(e.g., some frontier counties) (389).

Evaluating the Impact of the NHSC

NHSC success varies depending on its perceivedgoal. If the goal is to place providers in high-needareas, without regard to their length of service inthese areas, the NHSC has been very effective; 80percent of scholarship recipients completed theirobligation or were still serving in 1990 (346). Untilthe mid-1980s, communities served by NHSC pro-viders could rely on NHSC replacements if theseproviders decided to relocate on completion of their

obligations. Such communities might lack continu-

ity of service, but they were at least assuredpersonnel. However, recent declines in the numberof NHSC personnel will result in fewer replacementsfor these communities. The Scholarship Programplaced approximately 200 practitioners in 1988 andapproximately 120 in 1989 (662).

4In 1991, only 74

scholars will be available for placement (716).

If the goal is to create lasting systems of care, theNHSC could also be regarded as having been

reasonably effective. Thirty-five percent of NHSCscholarship recipients who completed their obliga-tions in fiscal year 1989 either remained at theirservice site or relocated to another HMSA (346).

41

A national survey of physicians practicing in small(fewer than 10,000 residents) rural counties foundthat 15 percent of these physicians were eithercurrently or formerly affiliated with the NHSC(405). A study of Virginia PPO physicians who

completed their obligations between 1981 and 1986indicated a practice site retention rate of close to 45percent (704).

42

The Volunteer and Loan Repayment Programshave been unable to fill the gap left by the dwindlingsupply of obligated NHSC scholars. The 635 physi-cians

43recruited to HMSAs through the Volunteer

Program in 1988 and 1989 (table 13-8) (663)

represent only 15 percent of the estimated number of physicians needed (4,104) to remove all primarycare HMSA designations in 1988 (see table 11-5).The 115 physicians placed under loan repaymentduring the same period represent only an additional3 percent of physicians needed. MLPs can substitutefor physicians in some of these sites, but the NHSChas recruited very few in recent years (table 13-10)(663).

Service-Contingent Scholarships for Nurse

Practitioners and Nurse-Midwives

From 1978 through 1981, the Federal Govern-ment provided $3.2 million to NP and nurse-midwifetraining programs to fired service-contingent schol-arships for students (720). Just over 400 studentswere awarded scholarships over the 3-year period.

‘lo’Numbers include nonphysician personnel.41A telephone ~Ww ~ late Jme 1989 of ~ physic~~ due@ ~mplete heir obligation ~ July Wked whetier or not they Were re *gin their

current pmctice, or moving to an HMSA or non-HMSA.



g4zSeven of the 29 PPO physicians departed to enter specialty_ pmgr~s.

AsExcludes Fedeti Loan Repayment program pticipmtS.


Although administratively separate from the NHSC,receipt of scholarship under this program was alsotied to a service obligation in a primary care HMSA.Unlike the NHSC program, however, the burden of finding a placement site was on the participant, andmany participants had considerable difficulty find-ing sites where they could serve.

44Participants

complained that their schools had not made explicitthe requirements of the scholarship contract andsometimes had even given them false information(720). In spite of the reported difficulties, however,from 70 to 75 percent of the students served theirobligations, approximately 15 percent repaid theirawards, approximately 4 percent were granted waiv-ers, and only 5 percent defaulted (720).

Satellite Clinics and Increased Utilization of

MLPs in Rural Areas

The satellite clinic model can address the healthcare needs of small and remote communities whileoffering the economic and professional advantagesof group practice arrangements. In this model,physicians or MLPs from a group practice located ina more urbanized community travel to remote sitesto see patients for a few days each week. Alterna-tively, some practitioners may staff the satelliteclinics full-time to reduce the time spent in transit

between sites. The physician-MLP team model cansuccessfully address the needs of remote ruralcommunities (see box 13-E). It can also help to easethe professional isolation and long work hours of rural physicians, MLPs have been found to increasephysician productivity (617).

Historically, MLPs have been more likely thanphysicians to locate in rural and undeserved areas,

but increasing demand for their services in urbansettings may change this (see ch. 10). In some States,restrictive nurse practice acts or reimbursementpolicies also influence the practice arrangements of MLPs and may discourage them from rural practicealtogether (see ch. 12). In other States, MLP-staffedclinics can be very effective (box 13-E).

Although overall trends in the numbers of ruralclinics staffed only by MLPs are not known, a study

of 44 such clinics which had existed in 1975 foundthat many had either closed or converted to physician-

only or physician-MLP staff structures (103). Theclinics with physicians on staff saw more patientsper week, charged higher fees, and relied to a lesserextent on nonrevenue funding sources than thosestaffed solely by MLPs (103).

RECRUITMENT AND RETENTIONIN THE PRIVATE SECTOR

Local Hospitals

Physicians

Rural hospitals, which rely on local physicians forpatient referrals, have a vested interest in theavailability of office-based physicians within theirservice areas. Hospitals may encourage physiciansto locate or to stay in the area to stay by offeringthem various types of assistance, including low-interest loans, subsidized office space, and guaran-teed income levels (see ch. 7).

Because such arrangements can be viewed ascompensation to a physician from an entity to whichhe or she refers patients, they may technically fallwithin the proscriptions of Medicare’s antikickback provisions (see ch. 7).

45Many rural hospitals had

hoped that recently proposed “safe harbor” regula-tions would provide some certainty in this area and

would uphold the legality of recruitment and reten-tion strategies that have proven essential for institu-tional survival. As discussed in chapter 7, however,the proposed regulations (issued in January 1989)offered little protection for any of these strategies.

Nurses

A study of nurses in rural Mississippi hospitals(453) attempted to identify retention strategies

nurses perceived as potentially effective. Thosemost frequently mentioned included opportunitiesfor upward career mobility, tuition reimbursementfor educational upgrade, bonuses based on years of service, improved pension plans, 24-hour clinicalconsultations, higher salaries for night and weekendshifts, and conflict management and resolutionmechanisms (453). A recent study found that wageincreases have repeatedly succeeded in reducing

past nurse shortages but have not kept pace with thepresent nursing shortage (7).

mentioned who were placed were



44R~ons mentioned included: com~tition for sit~ witi NHSC persomel, who were placed @-mu@ F~m~ ~d mgio~ offl~s ~d were @“m

priority; inability of facilities in qualifying areas (e.g., community health centers) to pay participants’ salaries; and unwillkgness of participants torelocate to quali@m“ g sites (720).

4SSeco 1128B of&e Socti Security A@ 42 U.S.C. Q132ti-7b.


Box 13-E—Examples of Midlevel Practitioner and Satellite Clinics in Rural AreasOregon—Sixteen of Oregon’s 44 r u r a l primary care clinics were staffed solely by NPs or PAs in 1988 (81).

Oregon law permits NPs to own and operate their own clinics and to practice without direct physician supervision.Legislation passed in Oregon in 1979 enabled PAs in State-designated medically disadvantaged areas to practicewith off-site physician supervision and to prescribe and dispense certain medications. Medicare and Medicaidreimburse for the services of PAs, NPs, and CNMs in clinics certified under the Rural Health Clinics Act (PublicLaw 95-210), and all private insurance plans in Oregon are required by statute to reimburse for NP services.Although some private plans do not cover the services of PAs, legislation currently pending in Oregon would requirethem to do so (81).

A clinic in Condon, a town of 750 people that is 70 miles from the nearest full-service hospital, is staffed bytwo full-time PAs who are supervised by a family physician 90 miles away (81). The supervising physician seespatients at the clinic for four hours once every two weeks, and maintains daily telephone contact with the PAs. ThePAs, who offer a wide range of basic primary care services, are accessible on a 24-hour basis. X-rays are readinitially by the PAs and diagnosis is confirmed by appropriate specialists. A radiotelephone is used to transmit EKGsto cardiologists in Portland for final interpretation. The clinic is certified under Public Law 95-210 and is supportedthrough a special tax district. It has attracted a dentist and a mental health specialist who lease office space and seepatients in the clinic 1 or 2 days a week (81).

A clinic in Dexter is owned by two NPs and is staffed by the owners and an additional NP (81). Annualincreases inpatient visits continue, indicating a high level of acceptance of the clinic staff by the community. Mental

health services are provided on a contractual basis by a mental health NP in a nearby town. Unlike the Condon clinic,the Dexter clinic is not supported through a special tax district, and with 40 percent of its service populationuninsured, it has had to adopt strict payment requirements. Financial constraints limit the scope of primary careservices it can provide. For example, X-rays must be taken at the consulting physician’s office until the clinic raisesenough money for its own equipment (81).

Kentucky—A physician in Hyden, Kentucky works in a joint practice team with six NPs in a network of 4 ruralclinic sites, a hospital, a home health agency, and an advanced school of nursing (602). The joint-practicearrangement greatly expands the number of patients the physician can treat directly or indirectly. It is not unusualfor one of the satellite clinics to serve as many as 500 patients a month (602).

A typical week for the physician involves 300 miles of driving to the hospitals and clinics. Each day beginswith patient rounds at the hospital and proceeds with services at one of the clinics. On Friday, the physician seespatients at the two busiest clinics, and then spends the afternoon at the home health agency or in administrativemeetings. The physician is also responsible for making home visits to assess the condition and needs of patientswhose care is then assumed by home health nurses (602). This unique and largely successful team approach ishampered by some regulatory obstacles. For example, due to Kentucky laws that prohibit NPs from prescribingmedication, they must contact the physician by telephone whenever such medications are needed.

Allied Health Professionals salaries and benefits, instituted scholarship pro-

A study of AHP supply and recruitment inFlorida’s small rural hospitals (572) found that,compared with urban hospitals, rural hospitals werepaying higher salaries to laboratory and radiographicpersonnel and higher entry-level salaries to nuclearmedicine technologists and respiratory therapists.Although most rural hospital AHPs were local

residents, a substantial proportion of laboratory andradiologic personnel commuted from urban areas.More importantly, rural hospitals recruited most of their new AHP staff from urban areas. Conse-

grams, improved management training , hired na-tional recruiting firms, and established committeesto address employees’ concerns (572).

Community and Migrant Health Centers

Approximately 800 NHSC physicians will com-plete their obligations at C/MHCs in 1990-91, but

due to a decline in obligated NHSC scholarshiprecipients, fewer than 250 replacements will beavailable (414). Physician shortages may be particu-larly severe in smaller rural C/MHCs that are more



quently, to compete with urban facilities for quali-fied personnel, small rural hospitals had increased

ysensitive to the loss of a single physician and havegreater difficulty finding a replacement (414).


To stem the projected physician shortfall, C/MHCs

must either retain NHSC physicians past the term of their obligations, or they must successfully recruitnon-NHSC physicians. The average salary of C/MHC primary care physicians is considerablylower than what those physicians would make in theprivate sector (411), and financial constraints limitthe ability of C/MHCs to compete with the privatesector for the physicians they need.

A 1987 study comparing recruitment and reten-tion strategies used in health maintenance organiza-tions (HMOs) and C/MHCs found that C/MHCslagged well behind HMOs in the breadth and extentof their activities (411). Only 48 percent of thecompensation components (e.g., pensions, associa-tion membership, cost of living increases, loanrepayment) and only 19 percent of the incentiveprovisions (e.g., extra compensation for weekend

work, teaching) used by HMOs were used byC/MHCs (411). Many HMOs use productivity-based incentives to attract and retain staff, but theDepartment of Health and Human Services hasreportedly discouraged C/MHCs from this practice(411). C/MHCs that do employ such strategies,however, have found them to be very effective (411).For example, the Southern Ohio Health ServicesNetwork, a private, nonprofit organization providinghealth services in 14 rural Appalachian communi-ties, modified its physician compensation plan bylinking annual salary increases to quality andproductivity (725). The development of this planwas viewed as a significant factor in the retention of 70 percent of the Network’s NHSC physicians aftertheir obligations had been completed (725). HMOsalso use loan repayment plans to recruit and retainphysicians, but C/MHCs cannot use their Federalgrant funds for such purposes (411).

C/MHCs do engage in preceptorship programs toa greater extent than HMOs and have found that theyaid in staff retention (411). Preceptorship programsnot only give C/MHC physicians the opportunity toteach but also help link C/MHCs to the academicresources of educational institutions. In addition,

these programs provide the centers an opportunity torecruit participating students (411).

In fiscal year 1989, the Bureau of Health Care

Delivery and Assistance (BHCDA) awarded ap-proximately $22 million in grants to C/MHCs toimprove personnel recruitment and retention (662).It is too early to evaluate the effectiveness of thisinitiative on the retention of NHSC physicians in orthe recruitment of new personnel to C/MHCs.

STATE EFFORTS IN HEALTH

PERSONNEL DISTRIBUTION

Where Federal and local efforts are unsuccessfulin overcoming shortages of health personnel, Statesmay step in. In fact, in an OTA survey of State ruralhealth activities conducted in 1988, States mostfrequently ranked personnel issues as the greatestproblem for the health of their rural populations (seech. 4). Although respondents noted that providerrecruitment and placement activities had addressed

some needs, many felt further program developmentwas warranted.

Table 13-11 shows how State officials rate certainFederal programs for improving the availability of health services to nonmetro HMSAs and MedicallyUnderserved Areas.

46The programs most frequently

listed as effective were the NHSC (35 States),C/MHCs (33 States), the Rural Health Clinics Act(21 States), and AHEC activities (15 States). Ironi-cally, the program most frequently listed as ineffec-tive was also the Rural Health Clinics Act (10States); it was followed by Medicare PhysicianBonus Payments (9 States) and AHEC activities (9States) .47 Responding officials in a number of Stateswere not familiar with Federal support of primarycare education programs, loan repayment programs,or the Medicare physician payment bonus.

State Activities

The number of health personnel distributionactivities varies considerably from State to State(table 13-12) (685). Programs most commonly usedin States to improve the geographic distribution of health professionals are placement services (43States), service-contingent loans and scholarships(36 States), service-contingent educational loan

repayment programs (27 States), targeted primarycare training opportunities (28 States), preceptor-

S f S l h l d di ll f f h



~esedatawefiomOTA’s 1989 Survey of State Health Personnel and Medically UnderservedAreaDesignations. Seeapp. Dforacopyof the surveyinstrument and a description of survey methods.

47~ tie tie States listing AHECS as “ineffective,” five did not have an AHEC, one had just started an AHEC in 1988, and tbree did have AHECS.


Table 13-11-States Officials’ Ratings of the Effectiveness of Selected Federal Programs in Improvingthe Availability of Health Services in Nonmetropolitan Health Personnel Shortage and

Medically Underserved Areasa

Number and percent of States rating the program as:

Federal program VE E I VI NF DK/NO NR

National Health Service Corps. . . 14( 32% ) 21( 48% ) 6( 14%) o (o%) o (o%) 2 (5%) 1 (2%)

Support of primary careeducational programs. . . . . . . . . . 2 (5%) 9(20%) 6(14%) 1 (2%) 5(11%) 16(36%) 5(11%)

Area Health Education

Center (AHEC) activities. . . . . . 3 (7%) 12(27%) 5(11%) 3 (7%) 1 (2%) 14(32%) 6(14%)

Community health centers. . . . . . . . 21(48%) 12(27%) 2 (5%) 1 (2%) 2 (5%) 4 (9%) 2 (5%)

Rural Health Clinics Act. . . . . . . . 5(11%) 16(36%) 8(18%) 2 (5%) 2 (5%) 8(18%) 3 (7%)

Medicare physicianbonus payments . . . . . . . . . . . . . . . . 4 (9%) 5(11%) 5(11%) 4 (9%) 3 (7%) 19(43%) 4 (9%)

Other . . . . . . . . . . . . . . . . . . . . . . . . . . 3 (7%) 1 (2%) o (o%) o (o%) o (o%) o (o%) 40(91%)

NOTE: VE = very effective; E = effective; I = ineffective; VI = very ineffective; NF = not familiar with

Federal program; DK/NO = don’t know or no opinion; NR = no response. Data from OTA’S 1989 survey of

States on health personnel shortage and medically underserved area designation (see app. D).

aonly 45 States responded to the survey.bother Federal Progrms specified included Cooperative Agreement Fund and Rural primarY Health care

Initiative. Two States specified State Programs: State physician training programs and State loan repaymentprograms.


ships (24 States), and AHECs (25 States) (table13-12).

48Other methods include malpractice insur-

ance subsidies, bonuses to physicians in ruralshortage areas, and recruitment travel assistance(627). Physicians made up the bulk of providersactually recruited by respondents to OTA’s survey,

but recruitment efforts were reported for a widerange of health professionals. Many States triedunsuccessfully to recruit NPs and PAs (see ch. 4,table 4-6).

To target resources to areas of greatest need,States may identify areas of health personnel short-age or medical underservice. While some Stateshave developed their own shortage area designation

criteria, many States lack the resources or theforesight to implement a designation program andrely on Federal designations to identify areas andpopulations of need. Three-fourths of States (34 of 45) responding to a second OTA survey on shortagearea designation activity

49used some type of short-

age area designation (either Federal or State), totarget their placement activities

50and 21 of these

were using their own designations to implement theprograms (see ch. 11).

A 1986 BHPr study found that in only one-half of the States was a State’s level of effort in healthprofessions distribution (as measured by number of programs, number of program participants, andprogram funding) related to the size of its underserv-ed and rural populations (table 13-13)(685). Statebudget constraints, politica1 climate, and number of slots in health professions training programs alsocan affect a State’s level of effort (685). The samestudy found that financial support for non-Federalhealth professions distribution programs increasedsubstantially from 1980 to 1985 (figure 13-2)(685).In nominal dollars, total support increased by 75percent during this time (from $42 million in 1980to $73 million).

Characteristics of Program Success

The 1986 BHPr study identified 113 healthprofessions distribution programs in 42 States (fig-ure 13-3) (685).

51In general, integrated strategies

~Nmbers ofs~~sref lect rewonses tothree separate studiescanied outbetween1986and 1989 (seetable 13-12). Someprograms maYhave~@discontinued, andprograms in some States may not bereflected.

49Seeapp. D.

~enrespondents indicated that their States did not have any healt.h personnel distribution programs using shortage area designation~ and 1



y p p g g grespondent answered “don’tknow.”sl~eseprogw are also reflected intable 13-12.




Table 13-13--States’ Level of Effort in Health Professions Distribution Compared With Their Unserved and

Nonurban Populations

Unserved population Percent nonurbanState Level of effort

a

(in thousands)b

population

Alabama . . . . . . . . . . . . . . . . . . . . . . . . . .

Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . .

Arizona. . . . . . . . . . . . . . . . . . . . . . . . . .

Arkansas. . . . . . . . . . . . . . . . . . . . . . . . .

California. . . . . . . . . . . . . . . . . . . . . . .

Colorado. . . . . . . . . . . . . . . . . . . . . . . . .

Connecticut. . . . . . . . . . . . . . . . . . . . . .

Delaware. . . . . . . . . . . . . . . . . . . . . . . . .District of Columbia . . . . . . . . . . . . .

Florida . . . . . . . . . . . . . . . . . . . . . . . . . .

Georgia . . . . . . . . . . . . . . . . . . . . . . . . . .

Hawaii . . . . . . . . . . . . . . . . . . . . . . . . . . .

Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Illinois . . . . . . . . . . . . . . . . . . . . . . . . .

Indiana . . . . . . . . . . . . . . . . . . . . . . . . . .

Iowa. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kansas. . . . . . . . . . . . . . . . . . . . . . . . . . .

Kentucky. . . . . . . . . . . . . . . . . . . . . . . . .

Louisiana. . . . . . . . . . . . . . . . . . . . . ., ,

Maine.. . . . . . . . . . . . . . . . . . . . . . . . . . .Maryland. . . . . . . . . . . . . . . . . . . . . . . . .

Massachusetts. . . . . . . . . . . . . . . . . . . .

Michigan. . . . . . . . . . . . . . . . . . . . . . . . .

Minnesota. . . . . . . . . . . . . . . . . . . . . . . .

Mississippi. . . . . . . . . . . . . . . . . . . . . .

Missouri. . . . . . . . . . . . . . . . . . . . . . . . .

Montana. . . . . . . . . . . . . . . . . . . . . . . . . .

Nebraska. . . . . . . . . . . . . . . . . . . . . . . . .

Nevada. . . . . . . . . . . . . . . . . . . . . . . . . . .

New Hampshire . . . . . . . . . . . . . . . . . . . .

New Jersey . . . . . . . . . . . . . . . . . . . . . . .

New Mexico. . . . . . . . . . . . . . . . . . . . . . .New York. . . . . . . . . . . . . . . . . . . . . . . . .

North Carolina. . . . . . . . . . . . . . . . . . .

North Dakota . . . . . . . . . . . . . . . . . . . . .

Ohio. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oklahoma. . . . . . . . . . . . . . . . . . . . . . . . .

Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pennsylvania. . . . . . . . . . . . . . . . . . . . .

Rhode Island . . . . . . . . . . . . . . . . . . . . .

South Carolina. . . . . . . . . . . . . . . . . . .

South Dakota . . . . . . . . . . . . . . . . . . . . .

Tennessee. . . . . . . . . . . . . . . . . . . . . . . .

Texas. . . . . . . . . . . . . . . . . . . . . . . . . . . .Utah. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Vermont. . . . . . . . . . . . . . . . . . . . . . . . . .

Virginia. . . . . . . . . . . . . . . . . . . . . . . . .

Washington. . . . . . . . . . . . . . . . . . . . . . .

West Virginia. . . . . . . . . . . . . . . . . . . .

Wisconsin. . . . . . . . . . . . . . . . . . . . . . . .

Wyoming . . . . . . . . . . . . . . . . . . . . . . . . . .

4

3

2

3

2

4

4

4

4

1

1

4

2

3

4

3

1

1

4

2

2

2

3

4

4

4

2

4

4

4

4

3

1

1

3

3

1

3

3

3

2

4

3

1

4

4

2

1

4

4

2

362

74

135

177

751

66

70

1865

608

592

18

128

909

210

78

33247

551

218177

49

353

73

395444

70

60

76

24

187

230562

461

68

554

111

164

558

31

253

84

291

864

61

31

283

126

282

273

38

4036164891921

29016361446173641334931

162053293353324737154815

281952512733323113465340

2016663427643637

aLevel of effort is derived from a combination of three variables: (1) number of programs, (2) funding, and(3) number of participants in the programs. “1” indicates the highest level of effort, while “4” indicatesthe lowest level of effort.

bThe estimated unserved population is computed by multiplying the number of practitioners in designated ‘eal-th

Manpower Shortage Areas by the population-to-practitioner cutoff ratio of 3,500:1 (in special cases,

3,000:1) and subtracting the figure from the area population.c

percentof State population residing in nonurban areas, 1980 census.

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration Bureau of



SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau ofHealth Professions, Office of Data Analysis and Management, Compendium of State Health ProfessionsDistribution Programs, 1986, DHHS pub. No. ODAM-2-87 (Washington, DC: U.S. Government PrintingOffice, 1986), table 4.

Chapter 13--Strategies To Recruit and Retain Rural Health Professionals q 365’

Figure 13-2—Funding Levels

for State Health Professions1980 and 1

$7 5

70

65 16 0 -

5 5 -

50 -

4 5 -

4 0 -

3 5 -

3 0 -

2 5 -

20 -

15 -

10 -

5-

o—

and Source of Funding

Distribution Programs,985a

P r i v a t e- Local

m Federal

_ State

4 % \ 41.6

5%1%

1%

1980 1965 1960 1965Nominal dollars Real dollars

b

%8 programs reported funding levels and sources in 1980 and 1985.bAdjust~ for inflation.

SOURCE: U.S. Department of Health and Human Services, HealthResources and Services Administration, Bureau of Health

Professions, Office of Data Analysis, and Management, Corn-pencfwm of State Health Professions Distribution Programs: 7986, DHHS Pub. No. HRP-0906964 (Rockville, MD: HRSA,November 1986).

using a number of different incentives were found to

be more successful than programs using only asingle strategy to increase the presence of healthprofessionals in underserved communities. Combin-ing educational and financial practice incentiveswith selective recruitment of students and practicesite development were found to reinforce healthprofessionals’ choices of specialty and practicelocation both during their education and throughouttheir career. As of 1986, however, many States were

still pinning their hopes and funding on separate,single strategies (685).

Of the 39 financial incentive programs identifiedin the BHPr study, 35 required service in designatedshortage areas (685). In general, service-contingentprograms were found to be an expensive butsuccessful means of attracting providers to rural andunderserved areas. The programs with strict buyout

provisions (e.g., high interest rates or other penal-ties) had the greatest success in getting students tofulfill their service obligations. Selective recruit-ment of students predisposed to rural practice

Figure 13-3-Focus of 112 State Health Professions Distribution Programs Identifiedby the Bureau of Health Professions, 1986

‘“:::::” /----7 m Experiences1% P r i m a r y

Loanscare

residencies2%

13%

Aid in

practice14 %

28’% I — - - - - - \ \ 12% I

O t h e r !

O t h e r

loan8

3 % kA

\\=+

/

acholar.s hipa1%

(e.g.,

Financial incentives35%

SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureauof Health Professions, Office of Data Analysis and Management, Compendium otState Health Professions Distribution Programs: 1986, DHHS Pub. No. HRP-0906964 (Rockville, MD: HRSA, November 1986).



g , )


students who grew up in rural areas) also improved

the success of service-contingent programs (685).During the past 2 years, a number of States have

passed legislation creating or expanding service-contingent scholarship, loan repayment, or tuitionreimbursement programs for health professionals inrural and underserved areas (118,196,197,208,283,301,311,358,364,365,366,371, 393,434,435,454,568,596,598,703,722). Oregon recently passed a lawrequiring the Oregon Health Sciences University to

selectively recruit medical students predisposed torural practice (454). Scholarships or loan repaymentfor underrepresented minorities have been approvedrecently in Louisiana (357) and California (118).

Programs to provide assistance to practitionersestablishing or maintaining practices in underservedcommunities are also common (table 13-12) (685).The BHPr study found that the effectiveness of theseprograms depended on the level of ongoing supportonce a practitioner had been placed (685). Programsproviding financial assistance for establishing apractice as well as technical assistance in managingand maintaining it had greater success in retainingpersonnel in undeserved areas than programs thatsimply acted as a placement service (685). RecentState activities include 1989 Oregon legislationestablishing tax credits for physicians practicing incertain rural areas (454) and legislation in NorthCarolina and Arizona authorizing compensation ormalpractice insurance subsidies for physicians pro-viding prenatal and obstetric care in rural andunderserved areas (53,444).

Many States use educational strategies to addressrural health personnel needs. Thirty-nine States havepublic medical schools, many of which were de-signed to produce more primary care physicians for

the State and to increase educational opportunities incertain areas (685). Graduates of public medicalschools are more likely to choose primary care andpractice in underserved areas than graduates of private schools (168,455). The BHPr study foundthat 8 States without their own public medicalschools purchased seats in other State schools. Of these, programs with a service commitment pro-duced proportionately more students who returned

to their home States (685).Some schools offer more specialized distribu-

tional programs. Eleven States in the BHPr study

had developed programs with targeted primary care

training opportunities in rural and underserved areas(685). Most of these programs reported that themajority of their graduates remained in the State topractice. Eighteen programs in 10 States providedspecial educational experiences (mostly rural pre-ceptorships) to undergraduate medical students (685).Recently, Texas, Nevada, and Hawaii have passedlegislation authorizing the planning or establish-ment of rural-oriented health professions trainingprograms (240,434,597). Maine and Florida havepassed legislation to establish special allied healthtraining programs (198,365). Other curricular inno-vations include enrichment programs to increase thenumber of students from minority and rural back-grounds, and the various activities of AHECs(685).

52For example, 1989 Oregon legislation

mandated that the State AHEC provide continuingeducation for rural physicians (454).

SUMMARY OF FINDINGS

General Strategies for Rural Recruitment

and Retention

Exposure to rural practice during health professions training can influence location decisions

as well as better prepare health professionals for the realities of rural practice. Decentralized educa-tional programs that offer training opportunities atrural sites are not only beneficial to the students, butthey may contribute to retention of providers alreadyin the area. These programs have demonstratedsuccess in placing their graduates in rural andunderserved areas. Selective recruitment of studentsfrom rural areas has also been found to increase theproportion of graduates who locate in rural areas.

Cross-training programs may improve the abil-ity of rural facilities to hire certain allied health

professionals as well as improve the attractiveness

of rural practice for these personnel. Trainingcould be provided in a formal educational setting oron the job. State licensing laws and hospital staffingrequirements that present barriers to the training anduse of multicompetent allied health personnel willhave to be made more flexible before such strategies

can be adopted.The Federal Government, through Medicare, sub-

sidizes GME. Medicare funding of GME does not

12 d i i ll f d ll f d d b fi



sz~e 12 -C s h tie 13~ study were originally federally funded, but now operate mostly on State fire.


distinguish among medical specialties on the basis

of undersupply, oversupply, or other indicators. If anything, Medicare reimbursement of GME puts

primary care training at a relative disadvantage,especially when the education takes place in ambu-latory care settings.

The Federal Government also provides sometargeted funding to primary care health professionseducation programs. With the exception of certain nurse and advanced nurse training programs,

however, such funding has decreased considerably during the past decade. Since 1980, targeted fund-ing of primary care graduate and undergraduatemedical education has decreased by more than 25percent. Federal support of PA training programs isapproximately one-half of what it was in 1981. Ascholarship program for NPs and nurse-midwiveswho agreed to serve in HMSAs was discontinued in1982. Federal support for allied health education

peaked at $30 million in 1974, but in 1990 only$726,000 were appropriated for allied health grantsand contracts.

AHECs are a source of innovative programs in rural-oriented health professions education, and they have been successful in recruiting and retain-ing health personnel in rural areas. AHECs havetended to emphasize physician rather than nonphy-

sician training. The unique funding mechanism of AHECs make them a model for Federal-Statecooperation in health professions training and distri-bution efforts. Some AHECs have come to play acentral coordination and research role for ruralhealth in their home States.

Medicare Reimbursement Strategies

The implementation of RBRVS for physician

payments under Medicare will probably enhance the incomes of most rural physicians. The full impact of the new payment system will not be felt forseveral years, and it is not yet possible to predict itsimpact on rural physician supply.

The impact of the Medicare Physician Bonus Payment Program, recently expanded to provide a10 percent bonus on Medicare payments for all

physician services provided in all rural primary care HMSAs, is also unknown. Current reportingrequirements are too minimal to enable an evalua-tion of the program’s impact. A 10 percent bonus onMedicare payment may be a sufficient incentive for

be sufficient to attract new physicians to HMSAs.Furthermore, the effectiveness of the program maybe reduced by the instability of the HMSA designa-tion. Small changes in the number of practitioners ina HMSA can result in existing physicians in thatHMSA becoming ineligible for the bonus.

Telecommunications networks can be used toalleviate professional isolation for rural practi-tioners, providing them with consultative oppor-tunities as well as continuing education. Locum

tenens services that provide temporary replacementsfor health professionals in remote rural areas canhelp to alleviate concerns over lack of vacation andprofessional leave time.

Strategies for Acute and Chronic Shortage

Areas

Service-contingent scholarship programs and

loan repayment programs have helped recruit health professionals to shortage areas and havebeen used by a number of States as well as theFederal Government. The most effective programshave been those that provide ongoing support toparticipants during their service obligation. Satellite clinic networks that use MLPs can also improve the availability of health services in remote areas. In some States, however, practice acts and reim-

bursement restrictions prevent the use of MLPs inautonomous settings.

Funding for the NHSC, which has placed morethan 16,500 health professionals in underservedareas since its inception in 1971, has decreaseddramatically in recent years. This decrease willmean a drastic reduction in the number of NHSCfield staff available for placement in a relativelystable number of designated shortage areas.

q The NHSC Scholarship Program, which has been almost entirely defunded, was highly successful in placing personnel in shortage areas. The Scholarship Program may be aparticularly appropriate incentive for healthprofessionals who would not be candidates forloan repayment due to lower levels of educa-tional debt (e.g., MLPs, nurses). The scholar-

ship program also provides valuable opportuni-ties for students who are economically disad-vantaged. Targeting scholarship funds to MLPsrather than to physicians might increase thetotal number of scholarships awarded without



p y yphysicians to stay in HMSAs, but it is not likely to

total number of scholarships awarded withoutincreasing overall expenditures.


q

q

q

The NHSC Federal Loan Repayment Programhas placed mostly physicians; probably due to

poor information dissemination, it was unsuc-cessful in attracting many MLPs.The NHSC State Loan Repayment Program hasnot been adequately tested. Only seven Stateshave been awarded funds, and they had insuffi-cient time in 1988 to award contracts.The NHSC Volunteer Recruitment Program,which began in 1988, has had notable successin placing physicians and other health person-

nel in lower priority HMSAs, but it might havea greater impact if additional incentives wereavailable to providers to locate in these areasand if additional recruitment staff were availa-ble.

In 1988 and 1989, the 750 physicians recruitedthrough the NHSC Federal Loan Repayment andVolunteer Programs represented only 18 percent of

the estimated number of physicians (4,104) neededto remove all primary care HMSA designations in1988. The Scholarship Program will place only 74practitioners (including nonphysicians) in 1991.Reductions in the number of NHSC commissionedofficers and NHSC-salaried civilian field staff alsoseriously limit the ability of the NHSC to placepersonnel in areas of the most critical need. ManyNHSC sites--particularly federally funded C/MHCs—

are faced with the impending loss of obligatedNHSC physicians for whom there will be noreplacements.

Private Sector Strategies

Rural hospitals may use financial incentives toattract physicians to the area. Such incentivesinclude guaranteed income, free office space, andloans; but the current vagueness of Medicare’s

antikickback provisions can make these strategiesdangerous for hospitals. Faced with the threat of future nurse shortages, hospitals are also focusing onnurse retention issues. For rural areas, key issues forhospital nurse recruitment and retention includeaccess to continuing education and opportunities forcareer advancement.

Federally funded C/MHCs, faced with the im-pending loss of 800 NHSC physicians in 1990, are

adopting new strategies to recruit and retain medicaland other staff. To date, however, many of these

strategies (e.g., linking salaries to productivity) havebeen limited by financial and administrative con-straints. It is too early to evaluate the impact of Federal grant funds made available to C/MHCs infiscal year 1989 for recruitment and retentionactivities.

State Activities

States responding to an OTA survey ranked personnel issues as the most pressing rural health problem. Thirty-eight of 50 States responding to thesurvey were involved in personnel recruitmentactivities, most of which were directed at physicianrecruitment. Several States reported unsuccessfulattempts to recruit NPs and PAs.

States use a wide range of recruitment methods,including service-contingent loan forgiveness and

scholarship programs, other financial incentives,rural-oriented health professions education, selec-tive recruitment of students, technical assistance inpractice development and maintenance, and place-ment services. The most effective State programs are those that employ multiple strategies--e.g., ascholarship or loan repayment program which bothplaces personnel in needy areas and provides themwith ongoing financial or technical support. Service-

contingent programs with high buyout penaltiesseem to be effective for temporary recruitment of health personnel to shortage areas, but retention of these personnel may require additional commitmentof resources. Cooperation among existing programsis key to program success.

State level of effort in rural health personnelrecruitment and retention varies widely and does notcorrelate with measures of ruralness or measures of need. State activity in and contributions to healthprofessions distribution programs have increasedsignificantly during the last decade, but many Statesstill rely heavily on Federal dollars to fired theseefforts. When asked what Federal programs hadbeen effective in improving health services availa-bility in rural shortage areas, State officials mostfrequently mentioned the NHSC, C/MHCs, theRural Health Clinics Act, and the AHEC program.



Chapter 14

Conclusions: The Availability

of Health Personnel in Rural Areas



rSUPPLY OF HEALTH PERSONNEL ~. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IDENTIFYING SHORTAGE AREAS: FEDERAL AND STATE EFFORTS . . . . . . . . . . . .RECRUITMENT AND RETENTION OF RURAL HEALTH PERSONNEL ...,.,,.. 372

Educational Strategies ... ... ... ... *., .**, ... **, ***. *.** e*** @e o.******,**.**,*,* 373Financial and professional Strategies ..*. ... ... *.. ... ... .., .cc**** *.** ****ace*** 374Strategies for Acute and Chronic Shortage Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . --. 375



Chapter 14

Conclusions: The Availability of Health Personnelin Rural Areas

SUPPLY OF HEALTH PERSONNEL

Although the supply of health professionals isrelatively lower in rural than in urban areas, it isprobably nonetheless adequate in many rural areas.Some rural areas, however, continue to have severeshortages of health professionals, even in the face of recent growth in national supply. Their situation islikely to worsen unless targeted efforts are made toattract health care providers. Other rural areas mayalso face inadequate supply in the future due toslower growth in national supply and competingdemand for primary care providers in urban areas.

Physician supply has increased over time in both

urban and rural areas. In fact, during the past decade,the most populated rural (nonmetropolitan) countiesexperienced even greater growth in physician supplythan did urban counties. However, rural areas in

general still have fewer health professionals per capita than does the Nation as a whole, and theleast populated counties have the fewest. In 1988,for example, rural counties had fewer than one-half as many patient care MDs per capita as did urban

counties, and small rural countiesl

had fewer thanone-fourth as many. Between 1979 and 1988, ruralcounties with fewer than 10,000 residents had a 17percent increase in the number of patient carephysicians per capita, compared with 25 percent inthe largest rural counties and 24 percent in theUnited States as a whole (686). Reductions in thenumber of new National Health Service Corps(NHSC) placements may further slow the diffusion

of physicians to less populated rural areas.

Most rural physicians are primary care physicians.

2Unlike most other specialties, the future

supply of primary care physicians is in danger.Projected shortages will disproportionately affectsmaller rural areas.

Although the exact number and location of communities with acute or persistent physician

shortages are impossible to determine, evidenceshows that a substantial number exist:

q

q

q

q

In 1988, 111 counties, all of which were rural,had no professionally active physician (511).As of December 1988, over 16 million people

(29 percent of the U.S. rural population) wereresiding in federally designated rural primarycare Health Manpower Shortage Areas (HMSAs).In comparison, only 9 percent of urban resi-dents were located in urban primary careHMSAs (665,686). If residents of qualifyingbut undesignated areas were included, thenumbers would be even larger. Rural HMSAsare concentrated in the South and in the West

North Central and Mountain States.Nearly 1,800 primary care providers (physi-cians or midlevel practitioners) would be neededto eliminate rural primary care provider short-ages in designated HMSAs (665).The number of rural primary care HMSAs hasnot changed appreciably during the past dec-ade.

Current national shortages of midlevel practitioners (MLPs), 3 registered nurses (RNs), and

allied health professionals (AHPs), along with projected national shortages of dentists, will simi-larly have a disproportionately negative effect on

smaller rural communities. The shortage of thesepersonnel, coupled with future declines in primarycare physician supply, may have serious implica-tions for the availability of basic health care in some

rural communities.Assessing rural health personnel availability,

particularly for nonphysicians, is severely hamperedby lack of national data. There are no recent nationaldata available on the rural/urban distribution of AHPs. Data on licensed practical/vocational nurses(LP/VNs) are also old, and national data on nursevacancies generally are limited to hospital andnursing home settings. Information on the distribu-

INo~e@ Wwties with fewer than 10,000 residents.

%Xteopath.ic physicians makeup a substantial proportion of these primary care physicians, particularly in small rural counties.3Mcludes nmse practitioners, physici~ assis~nts, Certfled n~e~dwives, ~d ce~led registered nurse anesthetists.



p ,

–371–


tion of physician assistants (PAs), certified nurse-midwives (CNMs), and optometrists is only availa-

ble by community size and does not permit rural/ urban distinction. It is therefore impossible tointegrate or compare data on the distribution of theseprofessionals with data on physicians. The commonbelief that PAs are more likely than physicians tolocate in rural areas, for example, cannot be con-firmed with currently available data.

IDENTIFYING SHORTAGE AREAS:FEDERAL AND STATE EFFORTS

To target limited resources effectively, Federaland State governments must be able to identifyneedy areas. Although much progress has been madeduring the past decade in developing criteria for thispurpose, Federal and State governments need tocoordinate and expand their efforts in order toidentify shortages of a wider range of health

professionals in a reamer more sensitive to localconditions.

Existing Federal designations can identify short-age areas nationwide according to a single set of basic criteria. However, they have a number of limitations:

Medically Underserved Area (MUA) designa-tions have not been reviewed since 1981.

The incentive to apply for designation hasprobably decreased due to the reduced availa-bility of Federal resources that flow to desig-nated areas and to a lack of State and localresources needed to identify areas. In 1986, forexample, there were 95 rural counties not

designated as HMSAs although they qualifiedon the basis of whole-county physician-to-population ratios (511).

4

Federal criteria do not currently take intoaccount measures of health care access such asthe level of insurance coverage in the area,which can have a significant impact on theavailability of services to the population.HMSAs and MUAs are very general measuresand cannot adequately identify local shortagesof particular providers or specific types of services (e.g., obstetric care).

Even with a more coordinated and active Federaldesignation program, State involvement will be

critical. State criteria and designations are morelikely than Federal designations to be sensitive to the

needs of specific areas, address specialty shortages,and respond quickly to changes in local conditions.

Programs that use provider-based designationssuch as the HMSA to target resources shouldrecognize the vulnerability of small rural areas todedesignation. Small rural areas can lose theirdesignation, and all associated resources, with thegain of even a single physician. One way to ensurethat the effects of these programs are long-lasting

might be to provide time-limited incentives that aretied only to the initial designation status of the area.Alternatively, designation status might be main-tained for a specified “grace period” after changesthat would otherwise precipitate dedesignation haveoccurred.

RECRUITMENT AND RETENTION

OF RURAL HEALTH PERSONNELThe future availability of health personnel in rural

areas depends on two factors. First, a sufficientnumber of health professionals must be appropri-ately trained to practice in rural areas (e.g., trained asgeneralists or primary care specialists). Second,rural areas must be able to attract and retain thesepersonnel.

Personal and professional concerns play at least as great a role as financial concerns in the location decisions of health professionals. Educational,financial, and other interventions must thereforework in concert to improve the attractiveness of ruralpractice. Strategies that have demonstrated effec-tiveness in improving the recruitment and retentionof rural health personnel in the past include:

q rural-oriented health professions training,

. selective recruitment of students with ruralbackgrounds or with interest in rural practice,

. service-contingent scholarship and loan repay-ment programs, and

q networks to provide continuing education andprofessional consultation to health profession-als in remote areas.

The Federal role in these strategies can be direct(e.g., placing personnel in underserved areas) or anindirect role of initiation and encouragement (e.g.,through support of rural health professions educa-

‘wDs Ooly,



Chapter 14--Conclusions: The Availability of Health Personnel in Rural Areas q 373

tion and State loan repayment or scholarship pro-grams).

Educational Strategies

Educational strategies can enhance the supply of rural health professionals by overcoming some of the personal and professional barriers to ruralpractice. These barriers include a lack of opportuni-ties for professional consultation, continuing educa-tion, or career advancement. Educational interven-tions can also help health professionals feel moreconfident practicing in semi-isolation. The FederalGovernment can pursue educational strategies bytargeting its health education resources to primarycare and rural-oriented programs and by supportingrural continuing education efforts.

The supply of rural physicians is greatly depend-ent on the supply of primary care physicians, butexisting trends increasingly result in medical stu-

dents’ seeking other specialties. The current trendaway from primary care medical specialties is linkedto professional and financial concerns of medicalgraduates, as well as to reduced availability of residency training slots. Targeted Federal fundingfor primary care undergraduate and graduate medi-cal training programs can give these programs agreater advantage, but such funding has decreased inrecent years. Weighting Medicare funding for gradu-

ate medical education would probably have an evengreater impact on the redistribution of resourcestowards primary care specialties, although it wouldprobably encounter some political opposition.

To increase the supply of rural primary carephysicians, targeted funding could be used todevelop and expand rural-oriented training pro-grams, which have been effective in placing theirgraduates in underserved rural areas. Current Fed-eral funding for primary care medical trainingsupports some rural-oriented training programs, butthere is neither a specific set-aside nor a specific setof curricular requirements for these programs. Toensure effectiveness, rural program funding mightbe tied to specific curricular components and/or tosome measure of outcome (e.g., proportion of graduates placed in rural areas).

Educational strategies are also key in the recruit-ment and retention of many nonphysician healthpersonnel. If more training programs were located in(or provided some training in) rural sites, more ruralstudents could be recruited. If access to advanced

nursing education in rural areas were improved, ruralpractice might be more attractive to nurses, and the

supply of advanced practitioners (e.g., NPs, CNMs,and certified registered nurse anesthetists) couldincrease. These practitioners, along with PAs, arecrucial providers in rural areas without enoughphysicians.

Specific nonphysician programs to target mightinclude:

programs to upgrade rural LP/VNs to RNs;

programs through which rural RNs can earnbachelor’s degrees;programs to train rural RNs as NPs, nurse-midwives, and nurse anesthetists;PA training programs;rural-oriented dental education programs;crosstraining programs for certain AHPs; andmultidisciplinary training programs with a ruralfocus.

Federal precedents exist for almost all of theseprograms, but few of them have a rural set-aside orspecific standards for participating rural programs.

Although data are scarce, it appears that shortagesof some AHPs are especially critical in rural areas.General rural shortages are compounded by the factthat many rural facilities cannot support specializedAHPs on a full-time basis. The training and use of multiskilled AHPs, however, are hindered by strictlicensure requirements, inflexible hospital staffingrequirements at both the State and Federal levels,and a lack of formal educational programs. Toaddress these issues, training programs could coor-dinate with State licensing boards in examining newcategories of AHP licensure; Federal and Stateauthorities could examine facility staffing require-ments; and Federal or State assistance could beprovided to establish local training programs andsupport traineeships in rural community colleges orhospitals.

Continuing education, which is required forlicensure of many health professionals, is particu-larly difficult to obtain in rural areas, either due tounavailability of accredited programs or the inabilityof rural practitioners to find temporary replacements

while they attend programs. The Federal AreaHealth Education Centers (AHEC) Program pro-vides a mechanism for addressing continuing educa-tion needs in rural areas, but its influence is notuniversal. Telecommunications can also be used to




provide continuing education, but programs areexpensive to develop and do not exist for many typesof health professionals.

Improved telecommunications networks can re-duce professional isolation, improve quality of care,and improve personnel recruitment and retention bylinking providers in remote areas to educational andconsultative resources. A number of model networksare already in place. The equipment and trainingcosts of starting such networks can prohibit theirdevelopment and successful implementation, how-

ever, and support may be needed to extend thebenefits of telecommunications to practices andfacilities that lack them.

AHECs provide both rural-oriented clinical edu-cation experiences and continuing education for avariety of health professional trainees. The AHECprogram is an excellent example of how Federalsupport can encourage State and local participationin activities addressing the geographic maldistribu-

tion of all varieties of health professionals. ExistingAHECs might be used as coordination points forother Federal health professions distribution pro-grams operating within or near their service areas(e.g., the NHSC and federally supported rural-oriented health professions training programs).

Financial and Professional Strategies

Health professions students may be dissuadedfrom primary care specialties by high levels of indebtedness, perceived higher incomes in the non-

primary care specialties, and other concerns. Inaddition, the high costs of education and reducedavailability of scholarship aid may prevent economi-cally disadvantaged rural students from pursuinghealth careers and returning to practice in rural areas.

Strong financial incentives may be needed toattract new physicians and other health professionalsto underserved rural areas. Remote communitieswill have increasing difficulty finding young physi-cians who are willing and financially able toestablish a private practice. Programs that helpstudents offset the high costs of education by directfinancing (e.g., scholarship programs) or by absorb-ing accrued debt (loan repayment programs) would

help to alleviate these problems. Such programscould be tied to a service obligation and/or toparticipation in rural-oriented training programs.The Federal Government has a history of involve-

ment in such programs, but its financial support hasdecreased considerably during the past decade.

Time-limited tax incentives, lump-sum bonuses,or other aid in practice for physicians, MLPs, andnurses in rural shortage areas may also help to offseteducation and practice expenses and income disin-centives. Such incentives could be tied to a limitedservice obligation and could be recaptured if theindividual were to leave the area before the end of hisor her obligation.

The financial disadvantages of rural practice forphysicians include fewer opportunities for salariedpractice and perceived lower practice income. Ruralpractitioners may face additional expenses such astravel to service sites and to required continuingeducation programs. Also, since a higher proportionof rural than urban residents lack health insurance,private physicians in rural practice may handlehigher volumes of uncompensated care.

Some Federal policies that address these financialdisincentives are already in place. For example,Medicare’s newly adopted method of paying physi-cians, the resource-based relative value scale, willprobably increase primary care physicians’ incomes,although its ultimate effect on rural physician supplyremains uncertain.

Medicare bonuses for physician services deliv-

ered in rural primary care HMSAs can also ease thefinancial burden of rural practice for some physi-cians, but again, the actual impact of this program onrural physician availability is unknown. To improvethe program’s accountability and the ability toevaluate its effectiveness, reporting requirementsand program evaluation could be made more rigor-ous (e.g., include evaluation of the characteristics of physicians who are availing themselves of the

bonus). The effect of Medicare’s bonus paymentsmight be further improved if States provided similarbonuses under Medicaid, expanding both thestrength of the incentive and the number of physi-cians it reaches.

MLPs are well-suited for practice in low-densityand underserved areas. The apparent recent trendamong some MLPs toward urban practice is unfortu-

nate for rural areas, particularly for those that maynot be able to attract and support the services of physicians. Rural areas would probably be more attractive to MLPs if existing barriers to autono-



Chapter 14--Conclusions: The Availability of Health Personnel in Rural Areas q 375

mous practice were addressed. Such barriers in-clude:

q

q

q

q

q

limited opportunities for Medicare, Medicaid,and other third-party reimbursement;State restrictions on scope of practice andprofessional autonomy, especially for PAs;lack of access to continuing education in ruralareas;malpractice liability insurance costs; andlack of acceptance by the medical profession.

Improved Medicare and Medicaid reimbursementfor MLPs could increase the number willing and ableto practice in remote settings. The Rural HealthClinics Act (Public Law 95-210), which promotesthe use of MLPs by guaranteeing indirect Medicareand Medicaid reimbursement for their services, hasnot been implemented in many areas due to regula-tory barriers, resistance from the medical profession,or simply through lack of interest or awareness of

eligibility criteria.Reimbursement policy needs to be carefully

coordinated with State practice acts to allow forprofessional autonomy while maintaining qualityand effectiveness through an adequate level of physician oversight. State regulatory changes couldbe guided by State or Federal models, and they couldbe influenced through Federal Medicaid policy.

Strategies for Acute and Chronic

Shortage Areas

Even with an adequate supply of health professionals, many communities will continue to have great difficulty recruiting providers, either because they lack a sufficient population base to support a practice or because they are otherwise perceived to be unattractive locations. Such areas are unlikely

to be able to maintain adequate health care accesswithout some degree of State or Federal interven-

tion.

The cornerstone of Federal efforts to addresschronic health personnel shortages has been theNHSC. The NHSC has tremendous potential forimproving the short-term and long-term supply of providers in such areas, but its effectiveness is

presently limited by funding constraints. In Decem-ber 1988 an estimated 4,104 primary care providerswere needed to remove HMSA designations, 1,794

of these in rural areas. In 1988-89, however, theNHSC placed 750 volunteer or loan repayment

physicians in HMSAs--only 18 percent of physi-cians needed to remove those shortages.

5The

number of obligated scholars continues to wane;only 74 will be available for placement in 1991.Although MLPs at one time represented a substan-tial proportion of NHSC field staff, the NHSC hasplaced very few in recent years.

All elements of the program--scholarship, loanrepayment, and volunteer-are needed to maximizethe program’s effectiveness. Loan repayment canattract health professionals with high debt loads(e.g., physicians and dentists) and can draw them toshortage areas immediately. Scholarships may bemore effective for recruiting health professionalswho spend less time in training and have lower debtloads. Scholarship programs also provide opportuni-ties to students who would otherwise be unable tofinance their education. To improve the retention of NHSC personnel, scholarships and loan repaymentcould be targeted to students in rural and primarycare-oriented training programs and to students fromrural and underserved areas. The volunteer programcould be more effective if it offered additionalincentives to providers locating in HMSAs, and if additional recruitment staff were available in theFederal and regional offices.

Many States are heavily involved in healthprofessions recruitment. Because their efforts aremore localized than federally administered pro-grams, State loan repayment and scholarship pro-grams might often be more effective in recruitingand retaining rural health professionals. They mayalso be in a better position to coordinate efforts fromvarious entities in the State to provide ongoingsupport for personnel serving in shortage areas. The

NHSC State Loan Repayment Program might en-hance these efforts; however, this fledgling programhas not been given an adequate trial and has not beenable to demonstrate its full potential. In addition,under its current structure, this program limits thetypes of personnel States can recruit to those withhigh debt loads (e.g., certain physicians). If fundscould also be used for scholarships, States couldrecruit a wider range of health professionals. The

Federal components of the NHSC are important forplacing personnel in areas not reached by Stateefforts.

s~e Propofion who were placed in nonmetro ms~ is *own.

20 810 0 90 13 QL3



20-810 0 - 90 - 13 QL3


In addition to the NHSC, the Federal Government in these areas. Such policies might include promot-could enhance personnel availability in rural areas of ing Medicare certification of rural health clinics and

chronic shortage through policies that promote encouraging States to overcome barriers to MLPsatellite clinics, particularly those staffed by MLPs, practice.



Part V

Two Examples of Specific Services



Chapter 15

Maternal and Infant Health

Services in Rural Areas

CONTENTS

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379MATERNAL AND INFANT HEALTH INDICATORS: URBAN AND RURAL

DIFFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379Infant and Fetal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379Low Birthright and prematurity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388

Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388MATERNAL AND INFANT SERVICES IN RURAL AREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389

Use of Prenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389Access to Rural Maternal and Infant Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390

MODEL RURAL MATERNAL AND INFANT SERVICE PROGRAMS . . . . . . . . . . . . . . . . . . . . 410SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412

Boxes Box Page

15-A. Obstetric Provider Availability: Selected State Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39115-B. Selected State Response to Obstetric Shortages and Malpractice Insurance and

Liability Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397

Figure



Figure Page15-1. Medicaid Coverage of Pregnant Women and Infants, April 1990 . . . . . . . . . . . . . . . . . . . . . . . 405

TablesTable Page

15-1. Selected Cause-Specific Infant Death Rates for Metro and Nonmetro Areas Adjustedfor Race, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380

15-2. Fetal and Infant Health Indicators by State and Metropolitan/Nonmetropolitan Area,1985-86 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381

15-3. Infant Death Rates and Fetal Death Ratios by Race in Metropolitan and NonmetropolitanAreas, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387

15-4. Percent of Births That Are Low Birthweight and Preterm by Metropolitan andNonmetropolitan Areas, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388

15-5. Fertility ’Rates by Metropolitan and Nonmetropolitan Residence, 1988 . . . . . . . . . . . . . . . . 38915-6. Maternal Mortality by Metropolitan and Nonmetropolitan Residence and Race, 1986 . . . 38915-7. Live Births by Month Prenatal Care Began, by Race and Residence, 1987 . . . . . . . . . . . . . 39015-8. Perinatal Health Care Indicators in Poor Rural Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39115-9. Live Births by Type of Birth Attendant, by Race and Place of Delivery, 1987..........392

15-10. Ratio of Active MD General/Family Practitioners, Active MD Obstetrician/Gynecologists,Active MD Pediatricians, and Active DOs per 100,000 Reproductive-Age Womenby State and Census Region and Division, 1987-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393

15-11. Number and Resident Population of Nonmetropolitan Counties Without an Active GeneralPractitioner, Family Practitioner, or Obstetrician/Gynecologist, by Region and State,1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395

15-12. Percentage of Family Physicians Who Care for Obstetric Patients at Various Levels,by Metropolitan/Nonmetropolitan Area and Census Region, July 1988 . . . . . . . . . . . . . . . . 3%

15-13. Percentage of Active AAFP Members Who Perform or Do Not Perform Routine ObstetricCare in Their Hospital Practice, by Region and Location of Practice, 1988 . . . . . . . . . . . . . 399

15-14. Adequacy of Prenatal Care for Medicaid Recipients and Uninsured Women,by Area of Residence, 1986-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401

15-15. Barriers to Earlier or More Frequent Prenatal Care Cited by Medicaid Recipients andUninsured Women Who Had Recently Delivered, 1986-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . 40215-16. Insurance Coverage of Women Aged 15 to 44 Years, by Residence and Marital Status,

1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-17. Strategies To Streamline Medicaid Eligibility, January 1990 . . . . . . . . . . . . . . . . . . . . . . . . . 40615-18. Proportion of Community Hospitals Reporting In-Hospital Births, by Hospital Bed Size

and Location, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40815-19. Average Number of Deliveries in Metropolitan and Nonmetropolitan Community

Hospitals, by Bed Size, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40815-20. Mothers With Ultrasound and Electronic Fetal Monitoring During pregnancy or Labor,

1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40915-21. Proportion of Community Hospitals With a Neonatal Intensive Care Unit, by HospitalBed Size and Location, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410



Chapter 15

Maternal and Infant Health Services in Rural Areas

INTRODUCTION

Nearly a million babies are born each yearlin

rural America. Maternity care for women andnewborn care for infants are basic components of thehealth care system and, like emergency services, areconsidered essential to a community’s public health

(207). Yet there is evidence that many rural commu-nities have lost or are losing the capacity to providethese basic services to their residents (525). Provid-ing maternal and infant services in rural areas can bedifficult, particularly in areas of very sparse popula-tions, because specialized providers and technolo-gies may be required. Further, transportation sys-tems must be available when obstetric emergenciesoccur that require the advanced systems of careusually found in urban areas.

This chapter reviews the status of rural maternaland infant health, evidence of problems in access toand availability of obstetric services and providers,and Federal interventions that affect access tomaternal and infant care. Lastly, the chapter de-scribes selected maternal and infant care programsthat have been effective in improving access to carein rural areas.

MATERNAL AND INFANTHEALTH INDICATORS: URBAN

AND RURAL DIFFERENCES

Infant and Fetal Mortality

In 1987, infant mortality2was 2 percent higher in

rural than in urban areas (10.07 v. 9.88 deaths per

1,000 births) (table 15-1).

3

In 1985-86, Wyoming,Idaho, and Maryland were among the States withhigh white infant mortality in rural areas (1 1.3,10.8,and 10.8 per 1,000 births), and Georgia and South

Carolina were among the States with high black infant mortality in rural areas (19.9 and 19.6 per1,000 births) (table 15-2). Causes of infant deathvary somewhat by urban and rural residence. In1987, infant death rates

4attributable to conditions

originating in the perinatal period, such as respira-tory distress syndrome, were somewhat lower, but

deaths caused by congenital anomalies, suddeninfant death syndrome (SIDS), accidents, and pneu-monia were somewhat higher in rural than in urbanareas (table 15-1).

In 1987, infant mortality rates were 2 percenthigher for whites but 8 percent lower for blacks inrural than in urban areas (table 15-3). Neonataldeaths-those occurring in early infancy, before the28th day of life-occur at about the same rate for

urban and rural whites, but the rate for blacks is 10percent lower in rural than in urban areas. Post-neonatal deaths-those occurring in later infancy,from 28 days to age one-are 10 percent higher forwhites but 3 percent lower for blacks in rural than inurban areas (table 15-3).

5The lower neonatal death

rate in rural areas is offset by higher fetal mortality.Fetal mortality ratios

6were 6 percent higher among

whites and 14 percent higher among blacks in rural

than in urban areas (table 15-3).7

The apparently higher incidence of fetal deaths inrural areas could be one cause of relatively low ruralneonatal death rates. It may be that babies whowould die at or before birth (and would be reportedas fetal deaths) in rural areas would be successfullyresuscitated and live for short periods of time inurban areas. When fetal and neonatal deaths are

combined (perinatal deaths), rural perinatal mortal-ity ratios are 2 and 3 percent higher than urban ratiosfor blacks and whites, respectively. Interpreting thedifferences in urban and rural fetal mortality is

lrn 1987, 22 percent of babies (839,335 of 3,809,394) were born to rural (nonmerropolitan) residents (650

%fant mortality, as measured by the infant mortality rate, is the annual number of deaths of infants less than 1 year of age, divided by the annualnumber of live births (J5).

3~ant mo~~ rates Wme s~n~~ed for race (white, black other race) using methods described by D~ Gup@ (159).

4Cause-speci.t3c infant death rates were adjusted to account for differences in the distribution of racial groups in urban and rural areas (J59).

SNwna~ mofii~ accomts for 65 ~rWnt of ~1 inf~t d~thso “rhe l~ing Muses of neom~ mo~ity we low bfiweigh~ prematurity, ~d

congenital anomalies, while the leading causes of postneomtal mortality are SIDS, congenital anomalies, and accidents (417).%e fetal mortality ratio is defined as the annual number of fetal deaths (of 20 weeks or more gestation) divided by the annual number of live births

(15,647).?Fetal, neonatal, and postneonatal mortality ratios/rates are shown for urban and rural areas by State in table 15-2.

–379-

















Chapter 15--Maternal and Infant Health Services in Rural Areas q 387

Table 15-3-infant Death Rates and Fetal Death Ratios by Race in Metropolitan and Nonmetropolitan Areasa, 1987

Metro NonmetroUrban Balance Urban Balance

Total placesb

of area Total placesc

of area

Infant mortality rated

. . . . . . . . . . . . . 10.2 10.8 8.6 9.8 10.2 9.7

m white infants. . . . . . . . . . . . . . . 8.6 8,9 8.0 8.8 9.1 8.7

q nonwhite infants. . . . . . . . . . . . 15.5 15.7 14.2 15.0 14.8 15.1- black infants. . . . . . . . . . . . . . . 18.1 18.1 17.7 16.7 16.3 16.9

Neonatal mortality ratee. . . . . . . . . . . 6.6 7.0 5.6 6.1 6.3 6.0

s white infants. . . . . . . . . . . . . . . 5.5 5.7 5.1 5.4 5.6 5.4

snonwhite infants. . . . . . . . . . . . 10.1 10.2 9.6 9.4 9.0 9.5s black infants. . . . . . . . . . . . . . . 11.9 11.9 12.3 10.7 10.1 11.0

Postneonatal mortality ratef. . . . . . . 3.6 3.8 3.0 3.7 3.9 3.7

s white infants. . . . . . . . . . . . . . . 3.1 3.2 2.9 3.4 3.5 3.3snonwhite infants. . . . . . . . . . . . 5.4 5.5 4.6 5.6 5.8 5.6

s black infants. . . . . . . . . . . . . . . 6.2 6.2 5.4 6.0 6.2 5.9

Fetal mortality ratiog

. . . . . . . . . . . . . 7.6 7.9 7.1 7.9 8.2 7.9m white infants. . . . . , . . . . . . . . . 6.6 6.7 6.4 7.0 7.3 7.0

snonwhite infants. . . . . . . . . . . . 11.3 11.0 12.7 12.5 11.9 12.8sblack infants. . . . . . . . . . . . . . . 12.7 12.4 14.8 14.5 13.7 14.9

aDeaths are recorded by maternal residence, not place of death.burban places in metro counties are those with populations of 10,000 or more in 1980.

curban places in nometro counties are those with populations of 10,000 or more but fewer than 50)000 ‘n 1980.%fant m rtality rate: The annual number of deaths among children Less than 1 year old as a proportion of

the annual number of live births.

% aaultal mrtali ty rata: The annual number of deaths during the first 27 days of life as a proportion of the

annual number of live births.fPosimcxlata.l,ortal.i tyrata: The annual number of deaths that occur from 28 days to age 1 as a proportion ofthe annual nuniber of live births.

gpet~ ~~ity ratio: The annual number of fetal deaths occurring at gestations of 20 weeks or more as a proportion of the annual number of live births.

SOURCE: U.S. Department of Health and Human Services, Centers for Disease Control, National Center for HealthStatistics, Vital Statistics of the United States, 1987, vol. II, Mortality, part B, DIMS Pub. No.

(PHS) 89-1102, table 8-2 (Washington, DC: U.S. Government Printing Office, 1989).

difficult because of regional variation in reportingfetal mortality (647).

The higher postneonatal mortality rates in ruralareas could be explained if deaths of high-risk infants were postponed beyond the neonatal period.This could occur if, for example, high-risk ruralinfants are less likely to survive after being dis-charged from remote tertiary centers because they

have limited access to continued specialty care andsocial service support (277). Another explanationfor the relatively high rural postneonatal mortality isthe higher incidence in rural than urban areas of infant deaths attributable to congenital anomalies,SIDS, and accidents—all significant causes of postneonatal mortality. In an Alabama study, infec-tion was identified as a contributor to the high ruralpostneonatal mortality (176).

There is limited information about the maternalrisk factors that increase the chances of having a fetal

or infant death. An equal proportion (30 percent) of pregnant women in urban and rural areas have atleast one medical condition that seriously affectspregnancy(8). Some information regarding smoking-associated risks is available from the 1985 HealthInterview Survey, which found that rural womenwere just as likely as urban women to reportsmoking cigarettes in the 12 months preceding the

birth of their last child (32 percent). However,women smokers in rural areas were more likely tocut down smoking and less likely to quit (38 percentcut down; 19 percent quit) than were urban women(35 percent cut down; 22 percent quit) (649).

Low Birthweight and Prematurity

Babies that are born too small or too soon are morelikely to die; if they survive they are more likely to

require hospitalization and very expensive, sophisti-cated care(417). There are only slight differences inlow birthweight rates

8between urban and rural

8bw.btiwei@tbabia aetio~bomwei@gless tkin51/2pOUd8(2,500gEiII@.






Table 15-5—Fertility Ratesa by Metropolitan and Nonmetropolitan Residence, 1988

Metro

Central Noncentral

Total Total city city Nonmetro

All races. . . . . . . . . . . . . . 69.7 68.5 73.1 65.4 74.6

white . . . . . . . . . . . . . . . 66.0 64.4 67.4 62.7 71.9

Black . . . . . . . . . . . . . . . 87.0 8 6 . 6 8 9 . 6 8 0 . 3 8 8 . 8

Hispanic.. . . . . . . . . . 94.0 96.6 96.3 97.1 58.2

aFertility ‘ates= annual live births per 1,000 women age 18 to 44.

bpersons of Hispanic origin may be of anY race.

SOURCE: U.S. Department of Commerce, Bureau of the Census, “Fertility of American Women: June 1988,” CurrentPopulation Reports, Series P-20, No. 436, table 4 (Washington, DC: U.S. Government Printing Office,

1989).

per 100,000 live births).14

As of 1986, the totalnumber of maternal deaths had declined to 272. In1986, maternal mortality rates were still slightlyhigher in rural than in urban areas, but the highestrates occurred in the most densely populated urban

areas (table 15-6).

MATERNAL AND INFANT

SERVICES IN RURAL AREAS

Use of Prenatal Care

Prenatal care prevents many poor pregnancyoutcomes, especially among women who are at highrisk of adverse outcomes, and augmented prenatalcare programs targeted to high-risk women appear toimprove the onset and frequency of prenatal visits(561,619). The three basic components of prenatalcare are (697):

q early and continuing risk assessment,. health promotion, andq medical and psychosocial interventions and

followup (which may include referral to, orconsultation with, other specialized providers).

Prenatal care ideally involves frequent provider-patient contacts that begin before or early inpregnancy (697). Rural women are slightly lesslikely than urban women to begin prenatal careduring the first trimester of pregnancy, but moreurban women have no prenatal care at all (table

15-7).

Table 15-6-Maternal Mortalitya by Metropolitan andNonmetropolitan Residence and Race, 1986

Number Death rate

of deaths per 100,000

Us. . . . . . . . . . . . . . . . . . .

Metro. . . . . . . . . . . . . . . . . .

Urban placesb

. . . . . . .

Balance of area. . . . .

Nonmetro. . . . . . . . . . . . . . . .

Urban placesc

. . . . . . .

Balance of area. . . . .

White. . . . . . . . . . . . . . . . . . .

Black. . . . . . . . . . . . . . . . . . .

All other. . . . . . . . . . . . . . .

272210

170

40

62

1349

146

117

126

7.247.22

8.40

4.51

7.30

6.98

7.40

4.91

18.83

19.40

aMaternal mortality rate is the annual number ‘

f

deaths related to pregnancy divided by the annual

number of live births.

bUrban places in metro counties are those with

populations of 10,000 or more in 1980.

cUrban places in nonmetro counties are those with

populations of 10,000 or more, but fewer than

50,000 in 1980.

SOURCE: U.S. Department of Health and Human Ser-vices, Centers for Disease Control, Nation-

al Center for Health Statistics, Vital Sta-

tistics of the United States, 1986, VO1.

II, Mortality, Part B, DHHS Pub FJo. (PHS)

88-1114, tables 8-9, 8-5 (Washington, DC:

U.S. Government Printing Office, 1988).

Women living in rural areas that include a largeeconomically disadvantaged population might beexpected to have less access to prenatal care. Thisexpectations borne out for white women; a greaterproportion of white pregnant women in poor ruralcounties

15received inadequate prenatal care in

14These mortalityrates wereadjusted for maternal age andrace (159).15PoorW~coutiesfic]ude&e332no~e@~ ~~tie~fi26 States~t~datl~t25 p~centofresid~tslivingbelowtheFeders.lpovertythreshold

in 1979(558).l6~dqwteprem~cWisei~acwe~t~@sdfig&e~d~estmofprepncyornoprem~cme(558).




Table 15-7-Live Births by Month Prenatal Care Began,by Race and Residence, 1987

Metro Nonmetro

Total births . . . . . . . . . . 2,970,059 839,335lst-2nd month. . . . . . 54.67 49.233rd month . . . . . . . . . . 20.16 23.434th-6th month. . . . . . 16.87 19.707th-9th month . . . . . . 3.91 4.54

No prenatal care. . . 2.08 1.46Not stated. . . . . . . . . 2.30 1.65

--------------------------------------------—-

White . . . . . . . . . . . . . . . . . 2,290,927 701,561

1st-2nd month . . . . . . 58.58 52.023rd month . . . . . . . . . . 20.00 23.614th-6th month. . . . . . 14.58 17.717th-9th month . . . . . . 3.28 3.87No prenatal care... 1.58 1.18Not stated . . . . . . . . . 1.99 1.61

----------------------------------------------

Black . . . . . . . . . . . . . . . . . 538,822 102,745lst-2nd month . . . . . . 38.88 34.413rd month. . . . . . . . . . 20.87 22.514th-6th month . . . . . . 26.25 30.657th-9th month . . . . . . 6.34 7.71

No prenatal care. . . 4.39 3.03 Not stated . . . . . . . . . 3.28 1.68


vices, Centers for Disease Control, Nation-

al Center for Health Statistics, unpublish-

ed tabulation from the Natality Statistics

Branch, November 1988.

198416

than white pregnant women nationally.Black women residing in such areas, however, were

more likely to have received adequate prenatal carethan black women nationally (table 15-8) (558).

171n

1985, infant mortality and the incidence of lowbirthweight were higher for both black and whiteinfants born in poor rural counties than in the Nationas a whole (table 15-8)(558).

Access to Rural Maternal and Infant Care

Available evidence suggests that fetal, infant, andmaternal mortality are somewhat higher and that lateprenatal care is more a problem in rural than in urbanareas. Access to maternity and infant care in ruralareas could be impaired by:

. absolute shortages of obstetric providers,

. shortages of obstetric providers who participate

in the Medicaid program,. a lack of insurance coverage and the inability topay for obstetric services,

. a decline in the number of hospitals equippedand staffed to provide obstetric services, and

q residents’ geographic isolation from servicesand poor access to regional perinatal caresystems.

Availability of Rural Obstetric Providers

Supply of Providers in Rural Areas--Informationfrom a number of State surveys indicates that therehave been declines in the availability of obstetricproviders (box 15-A). This, coupled with the lowpopulation density that characterizes many ruralareas, results in longer “travel times to obstetricproviders for rural than for urban residents (see ch.10, table 10-16).18

Maternity services may redelivered by any of three groups of providers: obstetricians, other physi-cians (primarily family physicians (FPs)), and otherpractitioners, such as certified nurse-midwives(CNMs). In 1987, births in urban and rural areaswere almost equally likely to be attended by aphysician, but nonphysician providers were mostlikely to deliver babies in the most urban areas

19(4.2

percent of births) and in the most rural areas20

(3.5

percent of births). Black women were more likelythan white women in both urban and rural areas tohave had a nonphysician provider (table 15-9).

Obstetricians provide most obstetric care in urbanareas, but in rural areas one-half to two-thirds of allobstetric care providers are FPs (349,543). In 1988,there were only 25 obstetricians per 100,000 womenof reproductive age in rural areas, compared with 61in urban areas (table 15-10). Obstetricians are evenless available in smaller nonmetro counties (see ch.10, table 10-11). The absence of obstetricians inmany rural areas is partially offset by the presence of general and family practitioners (G/FPs) (includingdoctors of osteopathy (DOs)) who are trained to

17D@the period Ig80 t. 1984,&e states with tie h@est levels of inadequate premtal care inpoornual counties Were ~ th e sou~west (i.e.$ NW

Mexico, Texas, Utiand

Arizona) (558).18Rw~ rwidents ~avel ~ave~ge of ~~u t e s t. ~ach ~ obste~ci~~~ologist ~d 20 ~u t ~ to r~ch m FP h con@w with urb~ residentswho, on average, travel 19 and 16 minutes to reach these providers (644).

l~rban plac~ within m@O Counties.

%onurban places in nonmetro counties.




Table 15-8--Perinatal Health Care Indicators in Poor Rural Countiesa

National Poor rural counties

White Black White Black

Infant mortality (1985). . . . . . . . . . . . . . . 9.3 18.2 10.0 19.2

Low birthweight (1985). . . . . . . . . . . . . . . . 5.6 12.4 6.6 12.6

Inadequate prenatal care (1984)b

. .,... 4.7 9.6 4.9 7.3

apoor rural counties include the 332 nonmetro counties in 26 States that had at least 25 Percent of residents

living below the Federal poverty threshold in 1979.bpercent of births t. women who receive either n. prenatal care or who began receiving care during their third

trimester of pregnancy, 1984.

SOURCE: J. Shotland, D. Loonin, and E. Haas, Off to a Poor Start: Infant Health in Rural America (Washington,DC: Public Voice for Food and Health Policy, October 1988).

deliver obstetric care. In 1988, rural areas had more there were 156 physicians trained to provide obstet-G/FPs (137 per 100,000 women of reproductive age) ric services (i.e., G/FPs, obstetricians, and DOs) perthan did urban areas (108 per 100,000 women of 100,000 rural women of reproductive age. In non-reproductive age) (table 15-10). trast, there were 242 per 100,000 in the rural areas of

The availability of rural physicians trained to States in the West North Central Region (tabledeliver obstetric care varies by region. In rural areas 15-10). Over half a million rural residents live in

of the East South Central region of the country21 counties that are without a physician trained to

zlsee app. F for a list of States in each e@on.




Table 15-9-Live Births by Type of Birth Attendant, by Race and Place of Delivery, 1987

Total number Attendantof deliveries Physician Midwife

aOther

Metro All. . . . . . . . . . . . . . . . . . . . . . . . 2,970,059 96.3 3.0 0.6

White . . . . . . . . . . . . . . . . . . . . . . 2,290,927 96.4 3.0 0.6

Black . . . . . . . . . . . . . . . . . . . . . . 538,822 96.1 3.2 0.7---------------------------------------------------------------------------------

Urban places 50,000+

All, . . . . . . . . . . . . . . . . . . . . . . . 1,483,338 95.7 3.5 0.7

White. . . . . . . . . . . . . . . . . . . . . . 993,102 95.6 3.6 0.8

Black . . . . . . . . . . . . . . . . . . . . . . 402,301 96.2 3.2 0.7

---------------------------------------------------------------------------------Urban places 10,000-49,999

All. . . . . . . . . . . . . . . . . . . . . . . . 579,993 96.6 2.9 0.5

White. . . . . . . . . . . . . . . . . . . . . . 485,907 96.8 2.7 0.5

Black . . . . . . . . . . . . . . . . . . . . . . 67,160 95.2 4.1 0.6---------------------------------------------------------------------------------

Balance of area All. . . . . . . . . . . . . . . . . . . . . . . . 9 0 6 , 7 2 8 9 7 . 1 2 . 4 0.5 White. ..........+.. . . . . . . . . 811,918 97.1 2.4 0.5

Black . . . . . . . . . . . . . . . . . . . . . . 69,361 96.9 2.4 0.7

Nonme t r o

AU. . . . . . . . . . . . . . . . . . . . . . . . 839,335 96.6 2.8 0.6 White. . . . . . . . . . . . . . . . . . . . . . 701,561 97.1 2.3 0.6Black . . . . . . . . . . . . . . . . . . . . . . 102,745 96.5 3.0 0.5

---------------------------------------------------------------------------------Urban places 10,000-49,999

All. . . . . . . . . . . . . . . . . . . . . . . . 183,260 97.1 2.5 0.4 White . . . . . . . . . . . . . . . . . . . . . . 146,735 97.4 2.2 0.4Black . . . . . . . . . . . . . . . . . . . . . . 29,343 96.4 3.2 0.3

---------------------------------------------------------------------------------Balance of area

All. . . . . . . . . . . . . . . . . . . . . . . . 656,075 96.5 2.9 0.6 White . . . . . . . . . . . . . . . . . . . . . . 554,826 97.0 2.4 0.6

Black . . . . . . . . . . . . . . . . . . . . . . 73,402 96.5 2.9 0.5

aMidwife includes lay midwives,and certified and noncertified nurse midwives.


Statistics, 1987 Natality, unpublished tabulation, November 1988.

deliver obstetric care (table 15-11),22and other areas

are without available obstetric services becausemany physicians trained to provide obstetric serv-ices do not provide them. In 1988, for example, therewas in North Carolina 1 nonmetro county without a

physician trained to deliver obstetric care (table15-11), but 18 nonmetro counties that lacked obstet-ric services because available physicians and CNMswere not providing them (512).

G/FPs are particularly well suited as obstetricproviders in areas of low population density becausethey can provide both obstetric and nonobstetric

care.23 Consequently, G/FPs generally require a

smaller population base (3,000 to 4,000 residents)than do obstetricians (who require about 11,000

residents) (331). In 1988, 9 out of every 10 FPs (91

percent) had hospital admitting privileges, but of these less than one-third (29 percent) reported thatthey currently practiced obstetrics (545). FPs in rural

areas are almost twice as likely as urban FPs to offer

routine obstetric care (43 v. 23 percent). There are,however, sizableregiona.ld.inferences in the extent to

which rural FPs provide obstetric care. Only 15

percent of rural FPs provide obstetric care in theSouth Atlantic region, compared with 70 percent inthe West North Central region (table 15-12).

~~con~t,~ere ~eo~y2 meho counties, witha total population of21,900, that are without a physician trained to provide obstetric ~.

~~1985,53permnt ofallphysici~ visits and 70percent ofaduhvisits to physicians inruralareas weretof-yphysicb (~’f~.



Chapter 15--Maternal and Infant Health Services in Rural Areas .393

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .





Chapter 15-Maternal and Infant Health Services in Rural Areas q 395

Table 15-11-Number and Resident Population of Nonmetropolitan Counties Without an Active GeneralPractitioner, Family Practitioner, or Obstetrician/Gynecologist, by Region and State, 1988a b

Number of Resident Number of Resident

nonmetro population nonmetro population

counties of counties of(A) column A (A) column A

United States . . . . . . . . 147

Northeast . . . . . . . . . . . . . . 1 New England. . . . . . . . . . 0 Middle Atlantic. . . . . . 1

New York. . . . . . . . . . . 1Midwest. . . . . . . . . . . . . . . . 59

East North Central . . . 4Illinois . . . . . . . . . . . 1Indiana . . . . . . . . . . . . 1

Michigan . . . . . . . . . . . 1 Wisconsin . . . . . . . . . . 1

West North Central. . . 55Kansas . . . . . . . . . . . . . 4 Missouri . . . . . . . . . . . 2 Nebraska . . . . . . . . . . . 22 North Dakota . . . . . . . 12South Dakota . . . . . . . 15

south . . . . . . . . . . . . . . . . . . 53

South Atlantic . . . . . . . 21Florida . . . . . . . . . . . . 2Georgia . . . . . . . . . . . . 15 North Carolina . . . . . 1 Virginia . . . . . . . . . . . 3

528,3004,900

04,9004,900

184,80025,5005,3005,4001,90012,900159,30012,60016,10048,00042,40040,200266,500118,20014,20073,3009,70021,000

South(continued):

East South Central . . . . . . 9

Alabama . . . . . . . . . . . . . . . 1

Kentucky . . . . . . . . . . . . . . 2

Mississippi . . . . . . . . . . . 3

Tennessee . . . . . . . . . . . . . 3

West South Central. .....23

Arkansas . . . . . . . . . . . . . . 1

Louisiana . . . . . . . . . . . . . 1

Texas. . . . . . . . . . .......21

West. . . . . . . . . . . . . . . .......34 Mountain. . . . . . . . . .......29

Colorado . . . . . . . . . . . . . . 6Idaho . . . . . . . . . . . . . . . . . 4

Montana. . . . . . . . . . . . . . . 11 Nevada . . . . . . . . . . . . . . . . 2

New Mexico . . . . . . . . . . . . 2Utah. . . . . . . . . . . . . . . . . . 4

Pacific . . . . . . . . . . . . . . . . . 5California . . . . . . . . . . . . 1Oregon . . . . . . . . . . . . . . . . 3

Washington . . . . . . . . . . . . 1

63,60013,20014,40019,200

16,80084,7008,20024,50052,00072,10058,30011,60013,10017,8003,2005,900

6,70013,8001,2005,0007,600

a I n c l ud e 5 physicians in patient CareI research, administration, and teaching. Includes all active doctors ofosteopathy (DOS) regardless of specialty.b~ data as of Jan. 1, 1988. DO data as of 1987. Population as of 1987.

SOURCE: T.C. Ricketts, Rural Health Research Center, University of North Carolina, Chapel Hill, NC. Analysisof unpublished data (provided by the Health Resources and Services Administration) conducted under

contract to the Office of Technology Assessment.

FPsin rural areas are much more likely than thosein urban areas to provide complicated obstetricdelivery services, services to high-risk patients, andcesarean sections (table 15-12) (545). Nonetheless,the majority of rural FPs do not handle complica-tions, so they are heavily dependent on obstetriciansfor backup.

CNMs are registered nurses with additional train-ing to provide obstetric and gynecological care toessentially normal newborns and women. As of 1990, nearly 4,000 CNMs had been certified by theAmerican College of Nurse-Midwives and an esti-mated 60 percent were providing obstetric services

24

(see ch. 10 for a discussion of the supply anddistribution of CNMs). Most CNMs are in urban

areas and most are employed by hospitals, HMOs,orbirth centers (44 percent) or by physicians (25percent) (342). Nearly 90 percent of CNMs that

deliver babies do so in hospitals (342), but practition-ers in many States report medical staff bylaws thatprohibit appointment of nonphysician care manag-ers. (See ch. 11 for a discussion of State regulatorybarriers that affect mid-level practitioners.)

The Impact of Medical Professional Liability

Issues on Obstetric Provider Availability in Rural Areas—In some cases, the conditions of ruralpractice have contributed to the decline of ruralobstetric providers—the lack of coverage for timeoff, limited consultation opportunities, and difficul-ties with referrals to larger hospitals (336). Increas-ingly, however, the high costs of premiums formedical malpractice coverage and fears of lawsuitshave been cited as major factors contributing to the

decline. A recent report of the Institute of Medicine(IOM) concluded that there has been a significantdecline in the number of obstetric providers practic-

~Es~tes~eb~edona lg88sueyof2,363mewrsoftiemeticmCollegeofNme-Mdtives.~esmeyre~memteww76pmcent(M2).




Table 15-12—Percentage of Family Physiciansa Who Care for Obstetric Patients at Various Levels,by Metropolitan/Nonmetropolitan Area and Census Region, July 1988

Complicated High Cesarean

Census region Routine care delivery risk sect ions

Total

Metro. . . . . . . . . . . . . 22.9 5.9 3.2 2.3

Nonmetro. . . . . . . . . . 43. 1* 23. 2* 15. 3* 12. 6*----------------------------------------------------------------------------

New England

Metro . . . . . . . . . . . . . 17.1 4.3 2.9 2.1Nonmetro. . . . . . . . . . 41.9* 10.5 5.8 2.3----------------------------------------------------------------------------

Middle Atlantic

Metro . . . . . . . . . . . . . 11.9 1.3 0.0 0.0 Nonmetro. . . . . . . . . . 18.2 3.6 0.0 0.0----------------------------------------------------------------------------

East North Central

Metro . . . . . . . . . . . . . 31.2 7.3 4.6 0.5 Nonmetro. . . . . . . . . . 60.9* 33.3* 24.1* 9.2*----------------------------------------------------------------------------

West North Central Metro . . . . . . . . . . . . . 48.6 14.4 7.5 4.8 Nonmetro. . . . . . . . . . 69.8* 42.9* 23.6* 19.8*----------------------------------------------------------------------------

South Atlantic Metro . . . . . . . . . . . . . 10.4 4.9 2.4 1.2 Nonmetro. . . . . . . . . . 15.0 5.0 2.0 0.0----------------------------------------------------------------------------

East South Central Metro . . . . . . . . . . . . . 8.5 1.4 0.7 0.7 Nonmetro. . . . . . . . . . 16.4* 9.4* 7.0* 6.3*----------------------------------------------------------------------------

West South Central Metro . . . . . . . . . . . . . 21.4 7.3 3.6 6.3 Nonmetro. . . . . . . . . . 39.7* 26.4* 23.1* 30.6*----------------------------------------------------------------------------

MountainMetro. . . . . . . . . . . . . 21.0 5.9 1.6 1.6 Nonmetro. . . . . . . . . . 58.4* 28.5* 24.1* 18.2*----------------------------------------------------------------------------

Pacific

Metro. . . . . . . . . . . . . 27.4 5.7 3.9 3.9Nonmetro. . . . . . . . . . 44.9* 22.4* 12.2* 16.3*

*NOTE: Statistically significant at P = 0.25 using a standardized normal Z test for comparing proportions

(a one-tailed test).

aBased on a sumey of active members of the American Academy of Family physicians.

SOURCE: G. Schmittling and C. Tsou, “Obstetric Privileges for Family Physicians: A National Study,” Journalof Family Practice 29(2):179-184, 1989.

ingin rural areas since the early 1980s. Furthermore, concluded that the costs of litigating obstetricala substantial number of providers are limiting the malpractice claims have not decreased greatly. Theirservices provided to high-risk women because they suggested interventions to curb the decline of fear being sued. Physicians are increasingly report- obstetrical providers included (289):ing a reduction in their Medicaid caseloads, at leastin part because of professional liability concerns q

(289).

A number of States have instituted reforms inresponse to concerns over obstetric malpractice q

costs (box 15-B). Nevertheless, the IOM report

State alternatives to the tort system (e.g.,

no-fault compensation for certain impairedinfants),

federally sponsored demonstration projects andstudies of proposed State legislation,




Box 15-B—Selected State Responses to Obstetric Shortages and Malpractice Insurance and Liability Issues

Arkansas--Established a grant program to increase access to nurse-midwifery services in medicallyunderserved areas (533a).

Arizona--Subsidizes physicians who provide obstetric services in rural areas (533a).

Colorado--Limits total liability to $1,000,000 and noneconomic losses to $250,000, makes physicians notliable where birth injury results from genetic disorders or other unavoidable natural causes, and establishes a 3-yearstatute of limitations (532).

Florida-In 1988,enacted an injured-infants plan that includes no-fault compensation, voluntary arbitrationsystems, and immunity for physicians treating patients in emergency rooms (367). Established a grant program to

increase access to nurse-midwifery services in medically underserved areas (533a).

Georgia--Makes loans to physicians who recently completed their medical education. Loans may be repaidthrough practice in rural areas. Priority will be given to physicians specializing in, and actively practicing, obstetrics(428).

Mississippi--Expanded the definition of “State employee” to include physicians providing services under acontract with the State so the physician avoids individual liability exposure (38)

Montana-Limits the immunity of providers who render birth-related services in emergency situations (292).

Nevada--In 1987, created a pretrial medicolegal screening panel in hopes of curbing the excessive cost of malpractice insurance. In 1989, Nevada malpractice premiums decreased 11 percent (505).

North Carolina--In 1988, funded a pilot program to compensate family physicians and obstetricians who agreeto provide prenatal and obstetric care in counties which are undersexed in respect to these services (331).

South Carolina--Expanded the definition of ‘State employee” to include physicians providing services thatare paid for by a salary appropriated by a governmental entity, thereby avoiding individual liability exposure (38).

Texas-Assumes limited liability for malpractice claims against doctors who provided at least 10 percentcharity care during the previous insurance policy year. Charity care includes services provided under the State’sindigent care program, Medicaid, Maternal and Child Health block grant programs, and primary health and migranthealth programs. Providers must still maintain malpractice insurance but eligible practitioners may qualify for apremium discount, in addition to added liability protection provided by the State (292).

Virginia--In 1987, enacted a no-fault compensation program for birth-related injuries (367).

Washington--Contracts with or directly employs qualified obstetric providers, then pays, through higherreimbursement, that portion of their malpractice premiums that represents the care they provided to eligible(indigent or underserved) pregnant women (292).

. a detailed, federally sponsored national data- . expansion of the National Health Service Corpsbase on malpractice claims that would include

information on malpractice insurance rates,payouts, settlements, and claims,

. more systematic assessment of new obstetricand related technologies,

. extending the personal immunities offered bythe Federal Tort Claims Act, or equivalentcoverage, to all practitioners of obstetric care atCommunity and Migrant Health Centers (C/ MHCs),

. State programs to indemnify or subsidize themedical professional liability premiums of obstetric providers who participate in Medicaidor otherwise provide care to low-income women,and

(NHSC).

FPs delivering obstetric services pay malpracticeinsurance rates that are two to three times higherthan those of their counterparts who do not practiceobstetrics (348). In some States, insurers are begin-ning to adjust physicians’ malpractice insurancerates for the number of deliveries performed (528).Where such adjustments are not made, however,insurance premiums continue to be a greater burden

for rural G/FPs and CNMs because these providersgenerally have fewer obstetric patients over whom tospread the cost. Physicians who provide backup forCNMs often have to pay additional malpracticeinsurance premiums (29).










Table 15-14-Adequacy of Prenatal Carea for Medicaid Recipients and Uninsured Women,by Area of Residence, 1986-87

Total Inadequateb

Intermediatec

Adequated

(1, 157 ) Number Percent Number Percent Number Percent

Large urbane

. . . . . . 507 128 25.25 233 45.96 146 28.80

Medicaid. . . . . . . . . . 197 42 21.32 94 47.72 61 30.96

Uninsured. . . . . . . . . 310 86 27.74 139 44.84 85 27.42

Other urban. . . . . . . . 3 4 8 6 6 1 8 . 9 7 135 3 8 . 7 9 147 4 2 . 2 4

Medicaid. . . . . . . . . . 198 30 15.15 81 40.91 87 43.94

Uninsured. . . . . . . . . 150 36 24.00 54 36.00 60 40.00

Rural . . . . . . . . . . . . . . 302 36 11.92 128 42.38 138 45.70

Medicaid. . . . . . . . . . 210 21 10.00 89 42.38 100 47.62

Uninsured. . . . . . . . . 92 15 16.30 39 42.39 38 41.30

aTheInstitute of Medicine prenatal care index (developed by D. Kessner) is used to classify the adequacy of

prenatal care.bcare beginning in third trimester or including 4 or fewer ViSitS for a PreW ancY of 34 ‘

r

‘ore ‘eeks-

ccare beginning in the second trime~er or including 5 to 8 visits for a PregnancY of 36 ‘r

‘ore ‘eeks-

deare beginning in the first trimester a; including 9 or more visits for a pregnancY of 36 or more ‘eeks.

ewomen delivering in 39 hospita ls in 32Tonrauniti.es in 8 States were interviewed. Large urban includes large

metro areas, other urban includes other metro areas.

SOURCE: U.S. Congress, General Accounting Office, Prenatal Care: Medicaid Recipients and Uninsured WomenObtain Insufficient Care, HRD-87-137 (Washington, DC: U.S. Government Printing Office, 1987).

nities without hospitals or other facilities are likelyto have greater access barriers to obstetric services.

Inability To Pay for Care

In 1989, the average charge for a vaginal deliveryin the United States was $4,334 (including physicianand hospital charges), but the average charge was

about 10 percent lower in rural than in urban areas(9,392).

35Women in rural areas, particularly poor

women, are more likely to have problems financingmaternity services because they lack insurancecoverage or their insurance does not cover maternityservices.

Most women in both urban and rural areas (77percent) have private insurance and a comparableproportion of rural and urban women of reproductiveage are uninsured (18 percent v. 16 percent in 1985)(9). Rural women, however, have more privateinsurance coverage through individual policies thatare less likely to cover maternity care (table 15-16)(9).

36Consequently, rural women are more likely

than urban women to be responsible for paying fortheir deliveries themselves. In 1982, 19 percent of

deliveries in rural areas, compared with 13 percentof urban deliveries, were classified as “self/family-pay’’ or "no payment.” Nationally, about 6 percentof total hospital charges are not paid and maternityservices account for about 40 percent of thisuncompensated care (392). In 1982, rural deliveriesaccounted for nearly one-half (46 percent) of all

uncompensated deliveries, yet rural deliveries repre-sent only 23 percent of all deliveries (9). Some of thedifficulties in paying for maternity care can be tracedto the fact that the rural poor are less likely than theurban poor to have Medicaid coverage (530) (see ch.2).

Medicaid—As of 1984, 17 percent of all deliverycharges were paid by Medicaid(9). Between 1975and 1990, the percentage of poor persons covered byMedicaid nationwide dropped from 63 to 50, butsubsequent congressional changes have reversed thetrend for pregnant women and infants (292). As of April 1990, all States must extend Medicaid eligibil-ity to all pregnant women and children up to age 6whose family incomes are at or below 133 percent of the Federal poverty leve1

37(Public Law l01-290).

35~eavmageckgeforams~e~defiverywas$7,633 (9). Thecosttodeliverand careforaprematurebabywithmajorcomplications mnbemuch

higher.36-ncepoliciestit~tioughemployers ofl5orfewwemployeesortitwenotemplo~at-related=not~kedto coverwttiv~e.

Nationally, approximately 9 percent of reproductive-age women (about 5 million women) have private insurance policies that do not cover maternitycare (8).

s7~e Fede~ poverty level in 1990 is $10,560 for a family of ~~ (4~9).



Table 15-15-Barriers to Earlier or More Frequent Prenatal Care Cited by Medicaid Recipients and Uninsured WomenWho Had Recently Delivered, 1986-87

All women Women with inadequate prenatal carea

Large Other Large Other

Total urban urban Rural Total urban urban Rural

(1,157) (507) ( 348) ( 302) ( 726) (361 ) (201 ) ( 164)

BarriersLogistical/access to health services:

Did not have anyone to take care of

other children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Could not miss work or school . . . . . . . . . . . . . . . . . . . .Did not have a way to get to clinic

or doctor’s office. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NO local doctors, midwives, or nurses. . . . . . . . . . . .Could not get a doctor, midwife, or nurse

to see them. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Did not know where to go for care. . . . . . . . . . . . . . . .

Felt the wait in the doctor’s office orclinic was too long. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Felt the office hours were not convenient. . . . . . . .

Could not get an appointment

earlier in pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cannot speak English well and could not

find anyone who spoke their language. . . . . . . . . . . .

Thought they might have problems

with immigration people. . . . . . . . . . . . . . . . . . . . . . . . .Women's attitudes, beliefs, and experiences:

Did not think it was important to see a

doctor, nurse, or another medical person

earlier or more often. . . . . . . . . . . . . . . . . . . . . . . . . . .

Did not want to think about being pregnant . . . . . . .

Had too many other problems to worry about

getting care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Did not know that they were pregnant . . . . . . . . . . . . .

Not sure they wanted to have the baby so didn’t

go to see a doctor, midwife, or nurse, . . . . . . . . . .

8.82

5.53

16.162.68

7.87

8.90

8.64

5.19

11.58

1.04

1.73

6.83

10.72

8.30

24.63

7.09

9.86

7.10

13.021.97

6.31

11.83

10.85

7.30

13.02

1.97

3.94

8.48

11.05

9.86

24.85

9.47

8.33

2.01

17.532.01

9.77

4.02

7.18

3.74

11.78

0.00

0.00

5.45

9.77

7.47

22.41

4.60

7 . 6 2

6 . 9 5

19.874.64

8.28

9.60

6.62

3.31

8.94

0.66

0.00

5.63

11.26

6.62

26.82

5.96

11.71

6.75

20.253.86

9.50

11.16

11.57

6.34

13.50

1.24

2.20

8.68

13.64

11.29

28.37

8.82

6.47

8.03

16.072.49

8.03

14.13

13.02

7.48

14.40

1.94

4.43

10.25

12.47

11.91

27.15

11.08

8.46

2.99

21.893.48

10.95

5.97

10.45

4.98

14.43

0.0

0.0

6.97

15.42

11.44

29.35

6.47

12.80

8.54

28.057.32

10.98

10.98

9.76

5.49

10.37

1.22

0.0

7.32

14.02

9.76

29.89

6.71






Table 15-16-insurance Coverage of Women Aged 15 to 44 Years, by Residence and Marital Status, 1985

Residential status/ Other Number of women

marital status Group Individual Medicaid government None in sample (1,000s)

All women.. . . . . . . . . . . . . 67% 10% 9% 4% 17% 56,152

Metro . . . . . . . . . . . . . . . . . . 68 9 9 3 16 41,610

Nonmetro. . . . . . . . . . . . . . . 65 12 8 4 18 14,543-----------------------------------------------------------------------------------------------------

Married women. . . . . . . . . . . 78 10 4 5 11 29,241

Metro . . . . . . . . . . . . . . . . . . 79 9 3 5 10 20,789

Nonmetro, . . . . . . . . . . . . . . 74 1 2 4 4 14 8 , 4 5 2- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Unmarried women. . . . . . . . . 55 10 15 3 23 26,912

Metro.. . . . . . . . . . . . . . . . . 56 10 15 2 23 20,821

Nonmetro. . . . . . . . . . . . . . . 52 12 14 3 25 6,092

NOTE: Percentages do not add Up to 100 because women may have insurance from more than one source.

SOURCE: Alan Guttmacher Institute, The Financing of Maternity Care in the United States (New York, NY:1987), p. 379.

As of January 1990, 4 States had extended Medicaid

coverage of these groups to 150 percent of the

Federal poverty level, and 15 States had extended

coverage to 185 percent, the fullest extent permitted

by tie Federal Government38

(figure 15-l) (see ch.3, table 3-3) (419). States categorized as "rural”

39

are less likely than “urban’’ States (30 v. 46 percent

of States) to have opted to extend coverage beyond

the level required by law.

Several States have streamlined the Medicaid

application and enrollment process, making it easier

for pregnant women to become eligible for coverage

quickly. Most States, for example, no longer review

pregnant womens’ assets when determining eligibil-

ity, but more “rural” than “urban” States review

assets (19 v. 8 percent) (table 15-17). Asset restric-

tions can result in exclusion from Medicaid cover-

age of poor rural families that have small farms,

work tools, or a car or truck (277).

“Rural” States are somewhat more likely than

“urban’’ States to offer continuous (85 v. 75 percent

of States) and presumptive eligibility (52 v. 46 percent of States) (table 15-17). States with continu-

ous eligibility do not require a women to re-

determine her eligibility during or shortly after her

pregnancy. Continuous Medicaid coverage is impor-

tant for rural families, who may have seasonal,

fluctuating income levels that could otherwise

periodically make them ineligible for benefits(277).

Presumptive eligibility allows publicly funded clini-

cal providers (e.g., C/MHCs) to make temporaryMedicaid eligibility determinations for pregnantwomen and provide services until they are formallyenrolled in the program. This option helps to ensure

that pregnant women, who in rural areas maybe farfrom the Medicaid application site, are cared forbefore and during the application process.

Placing Medicaid eligibility determination work-ers at public health clinics (in some areas on a circuitriding basis) or allowing mail-in applications wouldprobably facilitate Medicaid enrollment in ruralareas (277). Rural States, however, have been less

likely than urban States to “outstation” eligibilityworkers (26 v. 42 percent) to hospitals, local healthdepartments, prenatal care clinics, and C/MHCs(table 15-17).

Other Federal Sources of Services to Low-income Women—In addition to the Medicaid pro-gram, several Federal Government programs aredesigned to increase access to maternal and infantcare for poor and disadvantaged populations. Three

of these are described below.

The Maternal and Child Health (MCH) block

grant provides money to States to provide maternaland child health care to low-income, undeservedpregnant women, infants, and children (see ch. 3). In1987, $395 million was appropriated to the States(496), which used a portion of the money for free orsubsidized prenatal and well-child care in public

38&v~ S~teS ~ve ~~tm~ M~caid ~x~~ iO~ by ~~~ting State.fided pro- for pre~t Women an d children (4~9).

39~e 27 Shtes ti t ~~~ ~ tie top 15 for percmtofwpu~tion liv~g ~ nome~o ~=, or in the to p IS for nti~s of nonmetro residents, werecategorized here as rural. ‘I’he remaining States and the District of Columbia were categorized as urban (see ch. 2, table 2-2).



Chapter 15-Maternal and Infant Health Services in Rural Areas .405

Figure 15-1—Medicaid Coverage of Pregnant Women and Infants, April 1990

L \

I

L! District of Columbia

Percent Numberof of

poverty S t a t e sa

I I 133 3 0

1 3 4 - 1 8 4 4

u ~ 185 17 b

I

aNumber of States and the Disrict of ColumbiabAlaska uses State funds to extend coveraqe UP to 185% in some parts of the State. California, New Jersey, and Vermont use State tinds to extend Coveraae

to 200%. Massachusetts and Hawaii hav; passed legislation to’pravide universal across to health care-for all individuals in their States..

SOURCE: National Governors’ Association, “State Coverage of Pregnant Women and Childretianuary 1990,” Washington, DC, January 1990.

health clinics, health education, outreach to pregnant located in rural areas. Services provided includewomen, and transportation services. In 1987, MCH preventive care, family planning, diagnostic andblock grant expenditures accounted for about 10 emergency care, and transportation. More than

percent of States’ total maternal and child health 200,000 pregnant women received maternity care atexpenditures. At that time, State health agencies C/MHCs during 1988 (413). In many communities,used about one-third (31 percent) of MCH block C/MHCs are the sole source of comprehensivegrant funds-about $121 million-to support local maternity and infant health care.

40

health departments (496).

In 1988, and again in 1989, C/MHCs received $20Community and Migrant Health Centers provide million in additional funding

41to improve and

primary health care services, including maternity strengthen their capacity to serve pregnant womenservices, in medically underserved areas (see chs. 3 and infants. The funding was to be used to enhance

and 5). Sixty-one percent (319) of C/MHCs are the ability of C/MHCs to:

~one-fiiti of women rweive care from a public provider (e.g., a hospital outpatient departmen~ a C/MHC, or a Iocal health department), while theremainder receive premtrd care in private physicians’ offices (289).

dl~e additio@ funding c~e through DHHS’ infant mortality initiative.

20-810 0 - 90 - 14 QL3




Table 15-17-Strategies To Streamline Medicaid Eligibility, January 1990

OBRA 1986 Optionsa

Other State initiativesOutstanding

Dropped Continuous Presumptive eligibility Shortened ExpeditedStates assets test eligibility eligibility workers application eligibility

b

Alabama. . . . . . . . . . . . . . .

Alaska . . . . . . .. . . . . . . . . Arizona. .. . . . . . . . . . . . . Arkansas. . . . . . . . . . . . . .California.. . . . . . . . . . .Colorado. .. . . . . . . . . . . .Connecticut. . . . . . . . . . .Delaware. . . . . . . . . . . . . .District of Columbia. .Florida. . . .. . . . . . . . . . .Georgia. . . .. . . . . . . . . . .Hawaii. .....:.. . . . . . . .Idaho . . . . . . . . . . . . . . . . .

Illinois. . . .. . . . . . . . . .Indiana. . . .. . . . . . . . . . .Iowa. . . . . . . . . . . . . . . . . .

Kansas. .. . . . . . . . . . . . . .K e n t u c k y . . . . . . . . . . . . . .Louisiana. . . , . . . . . . . . .

Maine . . . . . . . . . . . . . . . . .

Maryland . . . . . . . . . . . . . .

M as s achu s e t t s . . . . . . . . .

Michigan . . . . . . . . . . . . . .Minnesota. . . . . . . . . . . . .Mississippi. . . . . . . . . . .Missouri . . . . . . . . . . . . . .Montana . . . . . . . . . . . . . . .Nebraska . . . . . . . . . . . . . .Nevada . . . . . . . . . . . . . . . .New Hampshire . . . . . . . . .New Jersey. . . . . . . . . . . .New Mexico . . . . . . . . . . . .New York. . . . . . . . . . . . . .North Carolina . . . . . . . .North Dakota . . . . . . . . . .Ohio. . . . . . . . . . . . . . . . . .Oklahoma. . . . . . . . . . . . . .

Oregon . . . . . . . . . . . . . . . .

Penn s y lvan ia . . . . . . . . . .

R h o d e I s l a n d . . . . . . . . . .

South Caro l ina . . . . . . . .

South Dakota . . . . . . . . . .

Tenn es s ee . . . . . . . . . . . . .

Texas . . . . . . . . . . . . . . . . .Utah. . . . . . . . . . . . . . . . . .

Vermont . . . . . . . . . . . . . . .

Virginia. . . . . . . . . . . . . .Wash ingt on . . . . . . . . . . . .

West Virginia . . . . . . . . .

Wiscons in . . . . . . . . . . . . .Wyoming . . . . . . . . . . . . . . .

Total . . . . . . . . . . . . . . .

xxxx

x

xxxxxx

x

xxx

xxxxxx

xxxxx

xxx

xxxxx

xxx

xxxxxxx

4 4

xx

xx

x x xx

x xx

c

xx

xxxxxxxxx

x x

x

xxc

x x xx

xxxxx

xxx

xxxxxx

xx

xxx

xxx

xxxx x

xx

xc

xx

c

x

x

xxx

x xc

xxx x

xxx x x

x

xxx

xxx

xx

xxx

41

x xx

x

xx

x

xxx

xx xxxx x

x x

25 17 1 9 9

%p t i o n s S t a t e s m a y p u r s u e t h a t w e r e i n t r o d u c e d b y t h o t i i b u s B u d g e t R e c o n c i l i a t i o n A c t o f 1 9 8 6 (s . . t e x t ) .bExpedited el~8ibility iS the p r o c e s s w h e r e b y S t a t e s u i v o priority in the Medicaid determination P~Oa* ~

a p p l i c a n t s w h o a r e p r e g n a n t .cFu t u r e iWlm e n t a t i o n d a t e .

SOURCE: N a t i o n a l G o v e r n o r s ’ As s o c i a t i o n , ‘State Coverage of Pregnant Women and Children-January 1990,” Washington, DC, January 1990.




q

q

q

q

provide comprehensive case-managed perina-tal ambulatory care services,

enrich the services of C/MHCs through addi-tion of staff for outreach, health care, andnutrition education,develop or expand service delivery systems forwomen and infants, including contractual ar-rangements with community obstetricians toserve patients at health centers that do not havetheir own obstetrical staff and formal referralarrangements with local and regional hospitals,

andbetter coordinate services between C/MHCsand other local public and private providers of health and health-related services (627a).

The infant mortality initiative funds were to betargeted to areas with high or increasing infantmortality rates. In 1988, however, this funding wassufficient to place projects in only one-third of health centers (206 centers), and many grantees did

not receive enough to carry out necessary activities(412).

The Supplemental Food Program for Women,

Infants, and Children (WIC) provides nutritioneducation and supplemental foods, such as infantformula, milk, eggs, and cereals, to low-incomepregnant or nursing women, infants, and youngchildren who are at ‘nutritional risk. “4

2In 1988,65

percent of WIC service sites were located in ruralareas43

and 40 percent of WIC participants wererural residents (730). In 1987, $1.6 billion in Federalfunds were used for the WIC program, but only 53percent of pregnant women, infants, and childrenwith incomes below the poverty level received WICbenefits (496,569).

Loss of Hospitals and Hospital-based

Obstetric CareIn 1987 almost all deliveries (over 98 percent) in

both urban and rural areas occurred in hospitals(650). Pregnant women need to be able to reach ahospital with delivery services within a relativelyshort period from onset of labor, but there are somereports that women in rural areas are traveling greatdistances to deliver their babies because local

services are unavailable (348). In SoutheasternMissouri, for example, some high-risk pregnantwomen have to travel over 250 miles to reach auniversity hospital for their deliveries; in Texas,some pregnant women are sent by ambulance todeliver their babies in hospitals 150 miles away(348).

When rural hospitals close, ready access todelivery services diminishes. However, availableevidence suggests that few hospitals that have closedwere the sole source of care in rural communities

(252) (see ch. 5). As of 1987, many more rural thanurban community hospitals with fewer than 300beds provided delivery services (85 v. 64 percent)(table 15-18). Smaller hospitals in rural areas aremuch more likely than comparable urban hospitalsto offer delivery services. For example, of hospitalswith fewer than 25 beds, less than one-third (29percent) of the urban hospitals but more than threefourths (77 percent) of rural hospitals report deliver-ies (table 15-18). Of hospitals that perform deliver-ies, rural hospitals have fewer births per hospitalthan do urban hospitals of comparable size. Inhospitals with 100 to 199 beds, for example, thereare on the average 451 births per rural hospital,compared with 790 in urban hospitals (table 15-19).

Evidence suggests that many patients are migrat-ing from rural areas to deliver their babies in more

distant urban hospitals:

q

q

q

A 1985 national health care consumer surveyshowed that almost one-half (47 percent) of rural residents were going to other areas forspecialized care, such as women’s services(303).

In the North Central States between 1980 and1987, there was a 20 percent decline in rural

births per hospital and a 5 percent increase inbirths per hospital in urban hospitals (577).

44

In 1988, 50 percent of pregnant women residingin rural Alabama did not deliver at the nearestrural hospital providing obstetric services. Here,women traveled to deliver an average of 23miles; over one-third went to hospitals in metroareas (102 b).

421qu&itioMI risk includes a history of poor pregnancy outcomes, iron-deficiency anemi% and inadequate dietary patterns.43ArM.s with a population of fewer than 25,000 were defined as ~.44whe~~ ~s shift ~cm~ ~ame of a lack of availability of delive~ servi~s, ~~e high-risk pregnanci~ were fiwingly being ~f~ed

to urban centers, or because patients chose to deliver in urban areas is unknown. Births represented 10 pement of rural hospital admissions in 1987 andso the shift of births to urban areas could jeopardize the financial stability of rural hospitals (577).




Table 15-18-Proportion of Community Hospitalsa Reporting In-Hospital Births,b

by Hospital Bed Size and Location, 1987

Metro Nonmetro(Total number of (Total number ofhospitals in hospitals in

Bed size Percent bedsize category) Percent bedsize category)

Total hospitals . . . . . . 64.3 (I, 957 ) 85.4 (2, 584 )

6-24 . . . . . . . . . . . . . . . 29.0 (31) 77.0 (200 )

25-49. . . . . . . . . . . . . . 54.5 (143) 81.5 (817)

50-99. . . . . . . . . . . . . . 57.4 (427) 86.0 (893)

100-199. . . . . . . . . . . . 63.9 (756) 92.0 (539)

200-299 . . . . . . . . . . . . 74.0 (600) 91.1 (135)

~omnunity hospitals,defined here as short-stay,non-Federal, nonspecialty hospitals (see app. C).bHospita19 reporting births are thosG reporting at least one birth.

SOURCE: Office of Technology Assessment, 1990.Data from the American Hospital Association’s 1987 AnnualSurvey of Hospitals.

Table 15-19--Average Number of Deliveries in Metropolitan and Nonmetropolitan Community Hospitals,a

by Bed Size,1987b

Average deliveries per hospital

Metro Nonmetro

Average (Number of Average (Number of

Bed size deliveries hospitals) deliveries hospitals)

Total hospital . . . . . . . . . 831 (1,259) 257 (2 ,207)

6-24. . . . . . . . . . . . . . . . . . 137 (9) 46 (154)

25-49. . . . . . . . . . . . . . . . . 183 (78) 96 (666)

50-99. . . . . . . . . . . . . . . . . 367 (245) 223 (768)

100-199. . . . . . . . . . . . . . . 790 (483) 451 (496)

200-299. . . . . . . . . . . . . . . 1, 261 (444) 818 (123)

aConraunity hospitals, defined here as short-stay, non-Federal, nonspecialty hospitals.bhalysis is limited t. those hospitals with fewer than

SOURCE: Office of Technlogy Assessment, 1990. Data


. In 1986, One-third or more of obstetric patientsin the service area of 25 of Washington’s 33rural hospitals

45were having their babies in a

hospital outside of their community. In somecases, patient outmigration occurred because acommunity hospital had stopped offering de-livery services, but 28 of 33 hospitals were still

offering obstetric services at the end of thestudy period (433).

Some reports link a decline in the number of physicians available to deliver babies to the closureof hospital obstetric units (336,591). It is difficult todetermine whether the precipitating factor was thatphysicians stopped delivering babies or that patientsleft the local hospital to deliver elsewhere. In one

300 beds and reporting at least 1 birth.

from the American Hospital Association’s 1987 Annual

case study, for example, nearly one-half (45 percent)of women who resided in a rural hospital service areawere driving over 50 miles to deliver even thoughthe local hospital had physicians on staff. Womenusing the local hospital were more likely to be under18 years old, unmarried, and not a high schoolgraduate than women traveling outside of the areafor care (591). That the number of deliveries peravailable physician declined before the physiciansthemselves began to drop obstetrics suggests thatpatient migration and a subsequently greater propor-tion of high-risk patients in their practices may haveprompted some local physicians to drop the service(591).

46In rural Alabama, evidence suggests that

rural obstetric units close because women stop using

~Rm~h oWi~~Wt i e d e fm~ ~ ~ a ~ ~ t ~ c ~ , i n p a t i e n tfaci l i t ies o f f e w e r ~ 5 0 ~ a n d l o c a ~ r n o r e t i 1 5 miles hmacity Of30,~p o p u l a t i o n o r g r e a t e r ( 4 3 3 ) .

t i ~ w ~ ~ t o ~ e ~study,thephysic~s ~ovi~mostof~e care wanted to continue to provide obstetric s=ims~t co~dnotsfford thernalpracticeinsurance (591).




Table 15-20-Mothers With Ultrasound and Electronic Fetal Monitoring During Pregnancy or Labor, 1980

Ultrasound duringa

b

Electronic fetal monitoring

pregnancy during laborc

Race RaceResidence All races White Black All races White Black

All locations. . . . . . 29.3 29.1 30.6 47.2 47.1 47.6 Metro. . . . . . . . . . . . . . . . 32.0 31.6 34.9 51.8 51.1 54.7

South . . . . . . . . . . . . . 31.1 31.7 29.8 50.4 49.6 53.4Other regions . . . . . 32.4 31.6 38.6 52.3 51.6 55.6

--------------------------------------------------------------------------------------

Nonmetro. . . . . . . . . . . . . 24.2 24.5 19.0 38.8 40.2 29.3South . . . . . . . . . . . . . 22.3 23.1 18.5 37.9 40.4 29.1Other regions . . . . .

25.6 25.4 -- -- 39.440.1 -- --

awomen with at least one ultrasound during Pre8nancY.bBased on 5,343 births included in the National Natality Survey.cBased on 7,504 births included in the National Natality Survey.

SOURCE: J.C. Kl e i nman , M . C o o k e , S . Machl in e t a l . ,~ (PHS) 84-1232 (Bethesda, MD: December

them. Here, large numbers of women migrated fromrural hospitals long before they stopped providingobstetric services (102b).

In contrast, a 40-bed hospital in Nevada pro-gressed from providing only 7 to 73 percent of thecounty’s deliveries through some deliberate stepsaimed at winning back obstetric patients after aperiod of patient outmigration to urban hospitals(5(95). These steps included:

q

q

q

attracting and organizing necessary personnel

and implementing a team approach with obstet-ric morbidity and mortality conferences,providing equipment such as ultrasound ma-chines and fetal monitors to improve carequality, andpublicizing the availability of obstetric serv-ices.

Some women may choose to obtain prenatal careand deliver in more distant hospitals because of

greater access to medical technologies. In 1980,pregnant women in rural areas were less likely thanurban women to receive ultrasound or electronicfetal monitoring (table 15-20). Urban/rural differ-ences were especially great for black women (322).

Communications technology is making it easierfor rural providers to offer obstetric monitoring totheir patients. Facsimile machines, for example, are

used by some rural practitioners to transmit fetal

“Variation in Use of Obstetric Technology,” Health. U.S.

1983).

monitoring strips to perinatologists in a distant

center for interpretation. If a problem is detected, a

helicopter and support team are dispatched to

transfer the mother to a regional center (132,259).

Access to Regional Systems of Perinatal Care

In the aggregate, events that may require special-ized care occur relatively frequently. Twelve percentof women have at least one major complication of pregnancy, 11 percent of women have a majorcomplication of labor, nearly 20 percent of deliver-

ies occur by cesarean section (8),47

and about 4 to 6percent of newborns require neonatal intensive care(619). For individual rural practitioners with smallobstetric practices, however, these occurrences arerelatively infrequent. To assure access to care whencomplications arise, regional systems of perinatal

48

care have been organized in some areas so thatlow-risk patients are cared for by primary carepractitioners in community hospitals and clinics

while high-risk patients are selectively triaged (andsometimes transported) to providers and facilitiesequipped to provide specialized care. These perina-tal centers are usually located in urban areas (549).In 1987, for example, fewer than 2 percent of ruralhospitals and 6 percent of urban hospitals with fewerthan 300 beds had a neonatal intensive care unit(NICU) (table 15-21). There are relatively fewerpediatricians in rural than urban areas to care for

seriously ill newborns (table 15-10).

47h 198(4 c e s ~ ~n section births occurred slightly more frequently in urban (18 percent) than rural ~~ (16 Pmcent) (9).

~Pe~~ refem to the period shortly before and after bi.r@ it is variously ddimti ssbe- with the completion of the 20th to 28th week of gestation and ending 7 to 28 days afterbirth.




Table 15-21-Proportion of Community Hospitalsa With a Neonatal Intensive Care Unit,by Hospital Bed Size and Location, 1987

Metro Nonmetro

(Total number of (Total number ofhospitals in hospitals in

Bed size Percent bedsize category) Percent bedsize category)

Total hospitals . . . . . . 6.4 (1, 957 ) 1.7 (2, 584 )6-24. . . . . . . . . . . . . . . 0.0 (31) 0.0 (200)25-49. . . . . . . . . . . . . . 0.0 (143) 0.0 (817)50-99. . . . . . . . . . . . . . .9 (427) 0.7 (893)100-199. . . . . . . . . . . . 4.6 (756) 4.3 (539)200-299. . . . . . . . . . . . 14.3 (600) 11.9 (135)

acomunity hospitals, defined here as short-stay, non-Federal, nonspecialty hospitals. Analysis is limited tohospitals with fewer than 300 beds.

SOURCE: Office of Technology Assessment, 1990.DataSurvey of Hospitals.

In many areas, regionalization appears to beconcentrating high-risk infants in facilities equippedto care for them (249,527). When physicians work-ing in community hospitals refer a large number of

high-risk obstetric patients, the need to transportsick neonates from these hospitals is lower. In Iowa,for example, 78 percent of very-low-birthweightbirths occur in specialized hospitals (249).

49In other

areas, a regionalized approach to perinatal care hasnot yet fully evolved. In upstate New York, forexample, many high-risk babies are still beingdelivered in small rural hospitals (155} A 1988study found that regionalized perinatal care systems

have generally deteriorated over the last severalyears. The study indicated that in some areascompetition has replaced cooperation among hospi-tals providing perinatal care (425). Furthermore,many community hospitals are upgrading theirneonatal programs, regardless of whether the num-ber of high-risk infants is sufficient to maintaineither professional skill levels or program economicviability (248,425).

There will always be a number of presumed“low-risk” deliveries that have unanticipated com-plications, so rural hospitals that offer obstetricservices must maintain the capability to performemergency procedures such as cesarean sections,which involve surgical, anesthetic, and post-operative capability (402). Alternatively, rural hos-

from the American Hospital Associations 1987 Annual

pitals can utilize transfer agreements and rapidtransportation systems to facilitate access to special-ized obstetric units and NICUs.

MODEL RURAL MATERNAL ANDINFANT SERVICE PROGRAMS

Several components of health care programs havebeen identified as contributing to declines in infantmortality in rural areas:

50

q

q

q

q

q

q

q

q

q

placement of publicly supported obstetric pro-viders in the community (e.g., physicians,CNMs, or nurse practitioners),the availability of obstetricians either locally oron a consultant basis,the provision of obstetric services for low-risk patients by public health nurses with supportfrom local physicians,the presence of perinatal transport systems andtraining,high WIC utilization,implementation of tracking and management

systems,program flexibility and a lack of strict programboundaries,interagency coordination and cooperation, andcommunity concern and leadership (465).

Demonstration programs funded privately andthrough the Federal Government have attempted to

4gs~~edhospi@5 include level NW an d t h r e e centers. Before th e r eg iona l i zed system was developecL tiew infants w~eJust ~ lilcelY to ~ bornin a level one hospital where resources needed to care for these infants may not have been available (249).

%e Bureau of Health Care Delivery and Assistance funded a study to ident@ factors that have contributed to decreasing infant mortality rates inrural counties over the past 15 years. The National Rural Health Association selected four communities to study in Louisiana, Texas, Montana, and SouthCarolina with populations between 10,000 and 35,000 (465).




redress problems of access to care and high infantmortality in rural areas. In addition, many States

have initiated innovative programs to improveperinatal outcomes.

The Rural Infant Care Program,51

funded from1980 to 1984 by the Robert Wood Johnson Founda-tion, was designed to give poor rural families accessto regional networks of perinatal care by linkingtheir local public health units, physicians, andhospitals with tertiary medical centers (517).

52An

evaluation of the program showed that infant mortal-

ity declined in the target populations and amonghigh-risk groups (223). Among the program compo-nents that were included were:

screening for high-risk pregnancies and provid-ing followup to those identified in specialclinics;implementing health education and nutritionprograms;

establishing neonatal hotlines so that localproviders could obtain medical consultation;implementing a system for transporting high-risk women in labor and newborn infants tohospitals with NICUs;using CNMs, nurse educators, and pediatricnurse practitioners to supplement physiciancare;conducting in-service education programs for

local providers; andtraining and employing lay outreach workersfor patient recruitment, follow-up, and transpor-tation to the clinic or hospital for care.

Federal programs implemented in the mid-1970scontributed to declines in infant mortality by facili-tating the development and use of perinatal centers(215). From 1976 to 1979,32 States plus the Districtof Columbia and Puerto Rico were funded throughThe Improved Pregnancy Outcome (IPO) Program53

to undertake the following activities (215):

q perform needs assessments for the provision of perinatal services;write State perinatal health care plans;define levels of perinatal care;educate providers of health care;

q

q

q

establish systems for perinatal data analysis,including the matching of birth and deathcertificates;

monitor and establish mechanisms for improv-ing quality of care for pregnant women andnewborns, including the creation of maternaland perinatal mortality committees; and

organize the flow of patients so that those withthe highest risk of a poor outcome could becared for in appropriate perinatal centers.

Through the Federal Improved Child HealthProgram (ICHP), 8 States were awarded 5-yeargrants to assist targeted counties in improving infantmortality (579). Evaluations of some of the projectslocated in rural areas show that they were effectivein increasing prenatal care use but unsuccessful inchanging the incidence of low-birthweight (468,579).

The MCH block grant program funds servicedemonstration projects, State staff developmentprograms, and other initiatives to help States de-velop their MCH programs (66). In 1989, forexample, 24 ongoing projects specifically related torural maternal and infant health care were fundedthrough the grant program (687). Among the fundedprojects were those supporting health promotion inrural black communities and consultation visits to

high-risk pregnant women in rural clinics by a teamof perinatal specialists (687).

In some rural areas, adverse overall economicconditions may overshadow the effects of specialhealth care interventions. A program implementedin an impoverished rural area in Appalachia

54failed

to improve neonatal mortality despite the operationof free hospital- and community-based clinics and

the provision of home health visits by outreachworkers (515). Despite the Indian Health Service’sregionalized system of perinatal care, which in-cludes nurse-midwives performing low-risk deliver-ies and trained indigenous workers providing home-based care, infant mortality is 11/2 times higheramong Native Americans than among all U.S.residents (616).




“

Innovative programs may be difficult to admin-ister in rural areas without a flexible approach. InCalifornia, for example, rural implementation of the

Comprehensive Perinatal Service Program,55

whichprovides risk assessments, prenatal services, casecoordination, and perinatal and parenting education,has been handicapped by strict program require-ments for support staff. Several rural counties do nothave the trained health educators, social workers,and registered dietitians that are required to admin-ister the program (133).


Fetal, infant, and maternal mortality are disproportionately high in rural areas. The fact that ruralwomen are less likely than urban women to receiveearly prenatal care probably contributes to therelatively high perinatal death ratios in rural areas.Sharp declines in the availability of rural obstetricproviders, leaving none in some areas, are exacerbat-

ing access problems. Over half a million rural residents live in counties that are without a physician trained to deliver obstetric care. Thereare fewer obstetricians available in rural than urbanareas, but G/FPs who provide obstetric servicespartially compensate for this deficiency. The pres-ence of physicians trained to provide obstetricservices varies widely by region. Southern Statesappear to have the fewest trained providers, and over

250,000 residents of 53 Southern counties arewithout obstetric providers.

In many areas, physicians trained to provideobstetric services are not doing so. Surveys of FPs,who are the primary source of obstetric care in

rural areas, show that rural FPs are almost twice as likely to be delivering babies as their urban counterparts and are providing a wider range of obstetric services. Nevertheless, while over 40

percent of rural FPs are providing routine obstetriccare nationally, fewer than 20 percent are providingroutine care in some rural areas of the South.

Several factors may contribute to a rural physi-cian’s decision not to practice obstetrics. There maynot be adequate coverage for time off, consultationmay be unavailable, and referrals to larger hospitalsmay be difficult to make. A number of States report

that a large proportion of physicians are eliminat-ing or limiting their obstetric practices as a direct

consequence of the high cost of malpracticeinsurance and fears of lawsuits. It is more difficult

for rural providers with small obstetric practices to

pay for malpractice premiums, because insurance rates often do not consider practice volume. Rural FPs not providing obstetric care are much morelikely than their urban counterparts to cite costs of liability insurance as a deterrent. Based on analyses

of AAFP survey data, there could be a significantincrease in the availability of FPs providing

obstetric care in rural areas if malpractice insurance premium costs declined. Two-thirds of C/

MHCs, important providers of obstetric care inmany rural areas, also report that medical malprac-tice problems have affected their ability to furnishobstetric services.

Uncertain is whether low obstetric provider par-ticipation in the Medicaid program is more of aproblem in rural than in urban areas. Representativesof MCH block-grant-funded and Medicaid programs

report particular problems with low physician partic-ipation in rural areas, and yet obstetric provider andconsumer surveys suggest that rural obstetric pro-viders are more likely to be participating. Neverthe-less, one survey of uninsured and Medicaid-insuredwomen showed that as many as 8 percent of womendelivering babies in rural hospitals could not get adoctor, midwife, or nurse to see them for prenatalcare.

Although CNMs are important potential provid-ers of rural obstetric services, they are few in numberand the majority are located in urban areas. Aninability to obtain malpractice insurance or physi-

cian backup, and in some cases, State practice laws have prevented nonphysician obstetric providers from practicing in rural areas.

Hospitals in rural areas are much more likely to

offer delivery services than urban hospitals of similar size. However, evidence suggests that insome rural areas women travel great distances todeliver their babies in hospitals outside their owncommunities. These patients may be attracted toobstetric services such as birthing rooms and sophis-ticated perinatal services and technologies. Whenpatient outmigration occurs, it is the well-insured,higher income, and well-educated patient who

leaves the local community for care, leaving behindthe uninsured and Medicaid patients. Rural provid-

ss~e Comprehensive pe~~ Service program is cosponsored by the Medi-Cal program and the State’s Maternal ~d Child Healti B~Ch.




ers left to care for these patients may find it difficultto maintain a practice or to afford liability coverage.There may also be an erosion of public confidencein local rural hospitals that may not have the capitalto invest in up-to-date obstetric equipment. Withouttechnological support, some providers may dropobstetric services, considering them too risky. Somerural hospitals experiencing patient outmigration forobstetric services have successfully reversed thistrend by reorganizing the existing obstetric service,upgrading equipment, and advertising availableservices. New communications technologies, such

as facsimile machines, are improving rural obstetricproviders’ rapid access to obstetric monitoringservices.

Although rural hospitals are much more likelythan urban hospitals to offer obstetric care, they aremuch less likely to offer specialized care. Regional-ized perinatal care helps to ensure that rural

residents have access to specialized care when

obstetric or neonatal emergencies arise, but thereis evidence that regionalized systems of care have

deteriorated over the past several years. PastFederal grant programs were successful in promot-ing the development of regionalized systems of perinatal care.

States are quite dependent on Federal resources to

provide maternal and child health services. In 1987,

nearly three-fourths (73 percent) of States’ maternal

and child health expenditures derived from Federal

sources (496). Federal programs such as Medicaid,

the MCH block grant program, and C/MHCs are

especially important in rural areas since rural

women are relatively less likely to have medical

insurance that covers pregnancy expenses. The

inability to pay for obstetric services is a serious

problem in rural areas—in 1982, rural deliveries

accounted for nearly one-half of all uncompensated deliveries.

Government or privately funded programs have

successfully reduced infant mortality in targeted

rural areas. Components of these programs that arefelt to have contributed to their success include

publicly supported obstetric providers, midlevel

practitioners, perinatal transportation systems, inter-agency coordination, and outreachrecruit patients and provide followup

tation.

workers thatand transpor-



Rural Mental Health Care



CONTENTS Page

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417RURAL MENTAL HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

Mental Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417Alcohol and Drug Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .418

FEDERAL PROGRAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418SERVICES IN RURAL AREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .420

Availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .420Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .424Other Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425

RURAL MENTAL HEALTH PERSONNEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426Mental Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426Other Rural Mental Health Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430Training for Rural Mental Health Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431

MENTAL AND PHYSICAL HEALTH LINKAGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Box

Box Page16-A. The Rural Mental Health Demonstrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421

Figure Figure Page16-1. Geographic Distribution of Counties With at Least One Provider and With No

Listed Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427

TablesTable Page

16-1. Stress Among Metropolitan and Nonmetropolitan Residents . . . . . . . . . . . . . . . . . . 41816-2. Prevalence of Mental Health Problems Among Nebraska Residents,

1981 and 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41916-3. Inpatient Mental Health Services and Beds by County Type, 1983 . . . . . . . . . . . . 42216-4. Percent of Community Hospitals Providing Psychiatric Services,

by County Type and Hospital Size, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42316-5. Alcohol and Drug Abuse Treatment Facilities: Location and Facility

Orientation, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42316-6. Percent of Alcohol and Drug Abuse Treatment Facilities Providing Specified

Services, by County Type, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42416-7. Alcohol Treatment Facilities by Client-to-Counselor Ratios and

Location, 1987 .. .. .,, . .., ....,.., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42416-8. Percent of Rural Community Mental Health Center Directors Who Expended

Efforts on Program Innovations, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42516-9. Non-Federal Psychiatrists by Metropolitan/Nonmetropolitan Location,

1975 and 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428

16-10. Average Number of Mental Health Professionals in Community Hospitals,by County Type and Hospital Size, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429

16-11. Percent of Counties Served by Mental Health Providers in Six States . . . . . . . . . . 430



Chapter 16

Rural Mental Health Care1

INTRODUCTION

Structurally, the mental health care system in theUnited States exists almost entirely apart from thephysical health care system, yet the two systemshave many parallels. Like the physical health

system, the mental health system is called on to offerpreventive services (e.g., educational sessions forparents of difficult children), other primary careservices (e.g., therapy for individuals suffering fromstress), inpatient services (e.g., for substance abusetreatment), followup and long-term care (e.g., forindividuals with chronic mental disorders), andon-site crisis services (e.g., for victims of violence).Mental health professionals comprise a wide varietyof social workers, nurses, clinical psychologists, and

psychiatrists.

In practice, however, the mental health services

available to individuals do not always appear as acoordinated whole, and the distinctions betweenphysical and mental health are often blurred. Family

practitioners, for example, are the providers of

choice for many individuals with mental healthproblems. Individuals in many other professions(e.g., the clergy, teachers and school counselors)also provide substantial amounts of mental healthcare. In rural areas, where the number and scope of providers and services can be very limited, theseproviders become an integral part of the mentalhealth “system.”

This chapter reviews existing data on the compar-

ative mental health status of rural and urban popula-tions. It then describes the major Federal programssupporting mental health care in rural areas andsummarizes what is known about the provision of rural mental health services and the availability of rural mental health providers. Finally, the chapterdiscusses models for linking physical and mentalhealth services.

RURAL MENTAL HEALTH

Mental Health Status

Reliable data on the prevalence of mental disor-ders in rural residents are scarce. Those availablesuggest that differences in mental health status

between rural and urban residents are slight.In the 1985 National Health Interview Survey, a

slightly smaller proportion of rural (nonmetro) thanurban residents reported that they had experiencedstress over the past 2 weeks, with women in eithersetting more likely to report stress than men (table16-1) (649). Rural residents were also less likely toseek help for a personal or emotional problem, evenafter accounting for their lower reported stress (seetable 16-1).

Using epidemiological data from North Carolina,2

researchers have found some minor differences inthe prevalence of mental health disorders amongurban and rural residents. Major depression andanxiety disorders were more prevalent among urbanresidents, while rural residents were more likely toreport cognitive deficits (e.g., memory deficits,

disorientation) (92,153). The researchers found norural/urban differences in rates of antisocial person-ality or schizophrenia (92). Small studies in otherareas have found that rural residents have higherrates of manic-depressive psychosis than urbanresidents (172) and are more likely to be clinicallydepressed (140), although the latter finding is notsupported by the North Carolina data.

National mortality statistics from 1980 suggestthat, after accounting for differences in age, sex, andracial distribution, rural residents have slightlylower suicide rates than do urban residents (0.11 v.0.12 per 1,000 residents) (626). Observers havereported high suicide rates in some economicallydistressed rural areas during the past decade (423),but it is not known whether overall rates haveincreased.

l~e pr~mation of this chapter was aided by the assistance of Lou Wienckows@ R~kviUe) ~.

2The Natio~~ti~te of hIen~ Health -) suppo~ ongo~g epldemiologlc~ r~se~hat Sk sites: IAXS Angeles, CA; B al t imore , ~; SL h)llk,

MO; New Hav e n j CT; D u r h a m . j NC; and the State of Colorado. No data from the Colorado site, which includes a rural sample, have yet been published.Of the other sites, only the North Carolim re,,earch explicitly has includal a ‘ ‘rural” sample. The population in this sample area has increased overhowever, and since 1983 the “rural” site has been categorized as metropolitan (734).

--417–

418 H lth C i R l A i




Table 16-1-Stress Among Metropolitan and Nonmetropolitan Residents

Percent of population reporting stress

All Men WomenMetro Nonmetro Metro Nonmetro Metro Nonmetro

Exposed to mental stress

in job (adults) in past year. . . . . . . 16.9 15.2 17.8 15.6 15.9 14.7

Experienced moderate or greater

stress within past 2 weeks. . . . . . . . . 52.7 47.1 50.8 45.4 54.3 48.7

Stress had some effect on

health in past year. . . . . . . . . . . . . . . . 44.4 43.2 38.5 36.1 49.7 49.6

Sought help for personal or

emotional problem in past year. . . . . 11.7 9.2 8.5 6.1 14.5 12.1


Statistics, unpublished data from the 1985 National Health Interview Survey.

Economic crises did apparently increase mentalhealth problems in some rural communities in the1980s. Beeson and Johnson found that, amonghouseholds in Nebraska, rates of psychologicaldistress for those in farm communities rose from thelowest in 1981 to among the highest in 1986 (table

16-2) (77). In North Dakota, also heavily dependenton the farm economy, the State Department of Human Services documented substantial increasesfrom 1980 to 1986 in domestic violence (from 950to 3,450 cases), child abuse (from 1,685 to 3,021cases), and death by suicide (from 73 to 93 cases)(423). Rural mental health facilities personnel inNorth Dakota cited depression as the primary mentalhealth problem in their communities (423).

Heffernan and Heffernan found that family stresswas a major concern among 42 families they studiedthat were forced out of farming (245). Nearly all of the adults became depressed upon leaving the farm,and over one-half continued to experience depres-sion. Common behavioral responses included with-drawal from family and friends, increased physicalaggression, and increased smoking or drinking.Children were reported to have become moreanxious, demanding, aggressive, and rebellious, andtheir academic performance worsened. Adolescentsincreased their use of alcohol and became morewithdrawn (423).

Alcohol and Drug Abuse

Drug abuse is less common in rural than in urbanareas. Use of and dependence on marijuana, cocaine,

hallucinogens, PCP,3

and heroin is less commonamong rural than urban residents in every age group

(92,643). There is some evidence that the popularityof particular substances in rural communities fol-lows urban trends, but at a lower level. For example,a study of a rural middle school in the Rockiesshowed marijuana use among students was ap-proaching urban rates by the late 1970s (736). In the

early 1980s, students at the same school adoptedmore conservative attitudes toward drugs and exhib-ited less marijuana use (735,737).

Alcohol dependence, in contrast, is apparentlyhigher among rural than urban residents (92). Ruraladults are more likely than urban adults to reportbouts of heavy drinking;26 percent of adult ruraldrinkers reported at least 5 days of heavy drinking in1985, compared with 24.5 percent of their urbancounterparts (649). The pattern is more complex inadolescents; compared with urban teenagers, ruralteens are more likely to have used alcohol but areslightly less likely to report days of very heavydrinking (643). Rural residents also report moredrinking and driving than urban residents (649).

Local factors can contribute to high substanceabuse. In a rural Michigan county with 16 percent

unemployment, almost one-fourth of 6th-, 7th-, and8th-graders surveyed reported occasional marijuanause, and one-fourth reported bouts of sickness fromdrinking. In both cases the frequencies were signifi-cantly higher than national norms (538,539).

FEDERAL PROGRAMS

Direct Federal involvement in the provision of

mental health care dates to the Community MentalHealth Centers Act of 1963 (Public Law 88-164),

spcp iS tie co~on abbreviation for phencyclidine.

Ch 16 R l M l H l h C 419



Chapter 16--Rural Mental Health Care q 419

Table 16-2—Prevalence of Mental Health Problems Among Nebraska Residents, 1981 and 1986

Percent of residents in area with mental health problem

Farma Rurala Urban a Large urbana

Scale 1981 1986 1981 1986 1981 1986 1981 1986

Depression . . . . . . . . . . . . . . . . . . 11 21 18 20 11 16 16 15

Anxiety . . . . . . . . . . . . . . . . . . . . . 11 12 16 17 12 12 13 12Psychosocial dysfunction. . . . 7 13 6 11 9 10 9 12

Cognitive impairment. . . . . . . . 18 15 15 13 14 16 14 14

General psychopathology. . . . . 12 13 11 14 13 15 17 12

Percent scoring high on

three or more scales . . . . . . . 6 15 8 11 7 9 8 9 Number of cases. . . . . . . . . . . . . 307 244 457 466 457 500 606 650

~ategories are based on Census Bureau definitions. “Ruralw

includes only individuals in conmnmities of fewer

than 2,500 residents who do not live on farms.

SOURCE: P.G. Beeson and D.R. Johnson, “A Panel Study of Change (1981-1986) in Rural Mental Health Status:

Effects of the Rural Crisis,” paper presented

Conference on Mental Health Statistics, Denver,

which authorized support for the construction of community mental health centers (CMHCS).

4The

Act required States to be divided into service

delivery areas (catchment areas) that each contained75,000 to 200,000 people. The legislation requiredthat centers provide inpatient, outpatient, and partialhospitalization services; emergency services; andconsultation and education services. Congress laterexpanded the CMHC model to include servicestargeted to specific populations (e.g., children, theelderly), substance abuse services, screening forcourts and other community agencies, and transi-

tional housing and followup care for those leavinginpatient psychiatric facilities (Public Laws 91-211,

94-63, 95-622, and 96-32). By 1981, 768 CMHCshad received grants and 296 of these (38 percent)were located in cities of 25,000 or fewer residents(483).

In 1978, Congress made CMHC funding contin-

gent on collaboration with related agencies, includ-ing school systems, child care agencies, courts,social service agencies, and health departments(Public Law 94-63). To facilitate collaborationbetween physical and mental health services, theNational Institute of Mental Health (NIMH) and theBureau of Health Care Delivery and Assistance(BHCDA)

5gave each of 58 community health

centers—two-thirds of which served rural areas—

funds to hire a mental health ’’linkage worker” to

a t the National Institute of Mental Health NationalCO, May 1987.

facilitate collaboration with CMHCs (457). The

program was terminated in 1981.

Subsequent mental health legislation in 1980

(Public Law 96-398) stressed services to under-

served and unserved populations, including (for the

fist time) rural residents. To receive a grant under

this legislation, however, rural CMHCs were also

required to serve at least one of the other targeted

populations (i.e., children, elderly, poor, or chroni-

cally mentally ill individuals).

The Omnibus Budget Reconciliation Act of 1981

(Public Law 97-35) consolidated most previous

mental health programs into a block grant, under

which funding was not contingent on providing

specific mental health services or targeting services

to specific population (see ch. 3). This legislation

repealed the collaboration agreement provisions of

the 1980 law, cut funding levels by up to 30 percent

(51), and eliminated most CMHC reporting require-

ments. Substance abuse grant funds were subse-

quently incorporated into the block grant (see ch. 3).

Because of the greater perceived substance abuse

problem in urban areas, Congress changed the

allocation formula for the grant in 1988 to give

greater weight to States with larger urban and young

adult populations (Public Law 100-690).

Recently, rural issues in mental health legislation

have regained visibility. In 1986, NIMH held two

Policy Forums on Rural Stress, where participants





reported high rates of suicide, depression, and stressin parts of rural America. Congress subsequentlypassed the Rural Crisis Recovery Program Act of

1987 (Public Law 100-219), which required theSecretary of Agriculture to provide one-time fund-ing for programs to develop educational, retraining,and counseling assistance for farmers and ruralfamilies adversely affected by the farm crisis.

6

Congress also appropriated $1.2 million to NIMHin September 1987 to establish Rural Mental HealthDemonstrations (Public Law 99-591). These were

designed to help States promote comprehensivehealth, mental health, and human services in ruralcommunities and to fund rural mental health pro-grams to address problems resulting from the farmcrisis. The law specified that only States mostadversely affected by the farm crisis would beeligible for funding. Thirteen States were identi-fied,

7and four-Iowa, Minnesota, Nebraska, and

South Dakota--each received $300,000 for a period

of 18 months to develop comprehensive rural mentalhealth programs (see box 16-A).

Legislation in 1988 (Public Law 100-690) re-quired that 15 percent of Federal funds appropriatedunder the block grant be set aside for rural mentalhealth demonstration projects. Since NIMH wasalready spending an equivalent amount of demon-stration money on rural projects, the legislation hadlittle immediate impact on federally funded efforts(547).

Unlike the general mental health programs, theCommunity Support Program (CSP), launched in1977, is designed specifically to assist States andlocal communities develop comprehensive systemsof care for adults with seriously disabling mentalhealth problems (580). Its goal is to provide emer-gency care while helping the individual reintegrate

into the community (by linking the individual withformal long-term support-e. g., food stamps, CMHCservices-and enhancing informal supportive net-works of families and friends). The program does notspecifically target rural areas, but several ruralcommunities have CSP projects and may benefitfrom its focus on integrated care, consumer involve-ment, and community outreach.

BHCDA and the Alcohol, Drug Abuse, andMental Health Administration (ADAMHA) recentlysigned an interagency agreement to provide funding

to primary care agencies for substance abuse pro-grams (343). The 3-year grant program began July 1,1989 and disbursed $9 million to nonprofit primarycare providers to develop plans to work withsubstance abuse treatment providers. Although theprogram might be highly appropriate to rural areas,due to the large number of grant requests all awardswere made to urban recipients (343).

In early 1990, NIMH established an Office of Rural Mental Health Research to coordinate andadminister relevant research and demonstrationstudies (141,641). This office will administer anewly advertised research effort that will includegrants to rural mental health research centers (640).

SERVICES IN RURAL AREAS

Availability

Mental Health Services

Recent information on mental health servicedelivery in rural areas is minimal. Since the consoli-dation of programs into the block grant in 1981,States have not been required to keep records orreport back to the Federal Government in any detailabout the population served in CMHCs or theservices clients receive. NIMH collects only sum-

mary information through two biennial surveys of mental health care facilities (6.38).

Based on the survey data, researchers havedocumented dramatic differences between rural andurban areas in the availability of local inpatientmental health services. Almost two-thirds of metrocounties (63 percent) had some kind of inpatientservices in 1983, but only 13 percent of nonmetrocounties had facilities that offered such services

(table 16-3) (705). Service availability among non-metro counties also varied enormously. Amongnonmetro counties with urban populations (by theCensus definition) of more than 20,000, 54 percenthad inpatient mental health services. In stark con-trast, only 7 percent of the 2,110 nonmetro countieswith smaller urban populations had inpatient serv-ices (705).

~s law built upon Public Law 99-198, which was less specific and did not actually require the Secretary of Agriculture to support outreach andother mental health services.

7~e 13 states were Colomdo, ~IWrgfi, 1owa, K~~, Mimesota, Mississippi, ~ssouri, Nebra@ Nofi D d c o @ c ) t ia h o ~ SOUth Ddcota,

Vermon t. and Wiscons in .

Chapter 16--Rural Mental Health Care .421



Box 16-A—The Rural Mental Health Demonstrations

The four Rural Mental Health Demonstrations were designed to assist States in developing comprehensive

mental health, health, job retraining, and employment services to rural communities. Although all included Stateand local components, they had very different emphases. An evaluation of the four demonstration projects wascompleted in January 1990 (147).

Iowa’s State component included:

q interagency col laborat ion (e .g. , wi th a State interagency rural crisis effort);

q knowledge development (e.g., a survey of the special services being provided by CMHCs to ruralpopulations, a mental health needs assessment based on a survey of rural Iowans);

q training programs (e.g., workshops for school counselors and mental health and allied professionals); and. technical assistance (e.g., to the Agricultural Extension Service’s rural outreach and counseling program).

At the local level, Iowa placed professionals or paraprofessionals directly in the communities served by five CMHCsto develop comprehensive outpatient, consultation, and education services (734).

Minnesota’s State program included:

s an interagency State Advisory Committee (which included both mental health and agriculture officials);. technical assistance to the local demonstration efforts; andq the development of a videotape on the problems of rural women, which was used at a teleconference to test

the value of teleconference technology for holding meetings among dispersed groups.

At the local level, the State funded outreach coordinators at three CMHCs, who implemented consultation andeducation activities in their catchment areas (e.g., a “peer helper” program at a local high school) (734).

Nebraska’s project included:q the development of educational materials (e.g., a pamphlet on stress management for rural adults, a teacher’s

guide to a curriculum for fifth graders on the emotional aspects of rural life);qa contract with Interchurch Ministries of Nebraska to provide training and evaluation support to that group’s

paraprofessional crisis hotline and field counseling efforts;q a conference on rural mental health; and. a data collection and literature review effort to appraise strategies for services integration.

The local direct service component of the project included two nontraditional models of mental health care: a‘‘circuit-riding’ mental health professional who rotated among three primary care physicians’ offices, and a mental

health professional located in a central “Ag Action Center’ who provided services to distressed farmers (734).South Dakota’s project differed from those in the other three States in that all but one CMHC in the State

participated. State-level activities were limited to:

. the development of educational materials (e.g., a directory of State human service resources for rural familiesand a pamphlet and two videotapes on rural mental health topics); and

. the development of materials to assist the CMHCs in designing their local projects (e.g., a needs assessmentsurvey and a survey of public service providers on awareness of CMHC services).

The local projects at the 10 participating CMHCs included educational activities aimed at the general public (e.g.,stress workshops); consultation and education activities for area human service providers (e.g., workshops for

educators and law enforcement professionals to help them understand and recognize mental health problems of ruraladolescents); establishment of peer support groups; and direct service outreach efforts (e.g., purchase of a mobileoffice) (734).

General acute-care community hospitals are the The availability in rural areas of comprehensivemost common providers of inpatient mental health mental health services is much more difficult toservices (216). Nonetheless, rural acute-care com- determine. The little existing evidence suggests thatmunity hospitals have fewer short-term psychiatric rural areas not only are less likely than urban areasinpatient beds than do urban hospitals (averaging 1.5 to have services, but where services exist they arev. 5.9 beds per hospital, respectively), and the narrower in scope. In a study of CSP deliveryrelationship holds true for hospitals of every size systems, the average number of services available tocategory (625). seriously mentally ill clients was more than 11 in all




Table 16-3-inpatient Mental Health Services and Beds by County Type, 1983

Number (percent ) Estimated median number Average number

of counties with of inpatient mental of facilities withsome inpatient health beds per county some inpatient

Number of mental health All Counties with mental health

County type counties services counties services services per county

All counties. . . . . . . . . . . . . . . . . 3,137 774 (25) o 52 2.5

Metro counties . . . . . . . . . . . . . . . 735 466 (63) 29 120 3.5

Nonmetro counties . . . . . . . . . . . . 2,402 308 (13) o 20 1.3

20,000 or more population. . . 292 158 (54) 11 20 1.3

Adjacent to metro area. . . . . 147 76 (52) 6 18 1.4

Not adjacent . . . . . . . . . . . . . . . 145 82 (57) 13 20 1.3

2,500 to 19,999. . . . . . . . . . . . . 1,325 145 (11) o 26 1.2

Adjacent to metro area. . . . . 560 57 (lo) o 32 1.2Not adjacent . . . . . . . . . . . . . . . 765 88 (12) o 20 1.2

Fewer than 2,500. . . . . . . . . . . . 785 5 (<1) 22 1.0

Adjacent to metro area. . . . . 221 2 (<1) o 20 1.0

Not adjacent. . . . . . . . . . . . . . . 564 3 (<1) o 22 1.0

SOURCE: M.O. Wagenfeld, H.F. Goldsmith, D. Stiles et al., “Inpatient Mental Health Services in Metropolitan

and Nonmetropolitan Counties,” Journal of Rural ConrnunitY Psycholo gy 9(2):12-28, 1988.

four urban areas studies but ranged from 8 to 10 inthe four rural study areas (228). Another study of

CSP participants found that rural clients were lesslikely than urban clients to receive needed services(567).

A 1979 study assessing mental health serviceneeds found that central cities, as expected, weremore likely than other areas to have available acomprehensive set of services. Catchment areas thatincluded both metro and nonmetro counties also hadrelatively high rates of comprehensive service avail-

ability. Surprisingly, within all-nonmetro catchmentareas, the least densely populated areas

8were actually

the most likely to contain a comprehensive set of services (355).

As is the case for inpatient psychiatric care, ruralacute-care general hospitals provide fewer outpa-tient, emergency, and specialty psychiatric servicesthan do their urban counterparts (table 16-4). Psychi-

atric outpatient services are provided by more thantwice as many urban as rural hospitals (14 v. 6percent, respectively) (625).

Emergency mental health services are particularlycrucial in rural areas. Rural residents with seriousmental illnesses rely more heavily than do urbanresidents on crisis services, even after accounting fordifferences in emergency service availability andneed (567). It is likely that the heavier rural usage isrelated to the lack of other mental health services

(567). But like other rural services, emergencymental health services face problems of logistics,

staff inconvenience, and costs entailed by coveringlarge distances (390). Providing on-site crisis serv-ices may be especially problematic. Rural crisisservices also reportedly use fewer techniques forneeds assessments, provide less public educationabout the service, and provide more limited trainingof crisis workers than do urban crisis services (390).

Observers have reported that, while urban areashave a variety of agencies and organizations offering

crisis programs, CMHCs are the principal ruralproviders of crisis services (390). Acute-care com-munity hospitals play a smaller role in rural areas;compared with almost 32 percent of urban hospitals,only 17 percent of rural hospitals provide psychiatricemergency services on site (625).

Substance Abuse Treatment Services

Alcohol and drug abuse treatment facilities arerelatively well represented in rural areas, althoughrural facilities serve a disproportionately smallnumber of patients. Seventeen percent of all treat-ment facilities are in nonmetro counties (see table16-5), but they serve less than 14 percent of allpatients (642). Eight percent of the alcohol-onlytreatment facilities are located in nonmetro counties,but these facilities serve only 5 percent of the totalpatient population. Possible explanations for thesefindings are that rural treatment availability is

8Nome~ ~omties ~ w~ch less than so percent of the population lived fi Cemus-defimed urb~ m-.




Table 16-4-Percent of Community Hospitals Providing Psychiatric Services,by County Type and Hospital Size,a 1987

Nonmetro MetroService 6-24 25-49 50-99 100-199 200-299 6-24 25-49 50-99 100-199 200-299

Child psychiatric

services. . . . . . . . . . . . . . . 15.8 2 9 . 5 0

0

0

4.5

4.5

1.6

0.8

4.9

1.6

12.3

3.3

4.1

11.5

5.5

5.8

12.7

9.9

14.6

4.4

5.8

11.0

13.1 24.5

17.7 33.6

32.8 50.1

18.8 36.4

27.1 39.4

8.7 17.0

12.7 22.6

20.3 29.1

0 1 . 3 5.1

Geriatric psychiatric

services. . . . . . . . . . . . . . . 1.6 1.7 6.4 1 6 . 3 3 6 . 4

Psychiatric emergency

services. . . . . . . . . . . . . . . 7.7 8.0

0.5 1.7

1 4 . 7

6 . 0

27.9

17.1

5 3 . 8

3 7 . 1Psychiatric education. . .

Psychiatric consultation

and liaison. . . . . . . . . . . .Psychiatric partial

hospitalization. . . . . . . .

3.8 3.7 10.3

4.6

1 9 . 4 37.9

3.8 1.2 9.1 18.9 0

Psychiatric outpatient

services. . . . . . . . . . . . . . . 2.2 2.8 4.5 9.9 24.2 0

0

Chemical dependency

outpatient services. . , . 3 . 8 5 . 3 8.5 14.6 23.5

aHospital size as measured by number of total beds. Specialty psychiatric hospitals and hospitals with more

than 300 beds are not included in this table. The number of nonmetro hospitals in the latter category is

very small.

SOURCE: Office of Technology Assessment, 1990. Data from the American Hospital Association’s 1987 Survey ofHospitals.

Table 16-5—Alcohol and Drug Abuse Treatment Facilities: Location and Facility Orientation, 1987

Facility type

Alcohol Combined

Location and facility function only alcohol and drug Total

Large metro areas (population more than 100,000)

Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prevention/education. ..., . . . . . . . . . . . . . . . . . . . . . . . .Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,383867

776

2,479

2,122

1,522

3,862

2,989

2,298

Other metro areasTreatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prevention/education. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Other,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

177

145

102

752

624

478

929

769

580

Nonmetro areasTreatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prevention/education. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

subtotalTreatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prevention/education. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Other, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total (unduplicated count). . . . . . . . . . . . . . . . . . . . . .

138

118

67

838

716

487

976

834

554

1,698

1,130

945

2,112

4,069

3,462

2,487

5,336

5,767

4,592

3,432

7,458

SOURCE: U.S. Department of Health and Human Services, Alcohol, Drug, and Mental Health Administration,

National Institute of Alcohol Abuse and Alcoholism, unpublished data from the National Drug and

Alcoholism Treatment Unit Survey, Oct. 30, 1987.

greater than demand, that rural facilities are smaller abuse facilities as a whole (642). Mental health

than urban ones, or that rural residents are less centers (e.g., CMHCs) are the most common sites forwilling than urban residents to seek help for mental alcohol treatment in rural communities, accountinghealth problems or from local facilities. Rural for 42 percent of the alcohol treatment caseloadresidents are slightly underrepresented in substance (642).




Table 16-6-Percent of Alcohol and Drug Abuse Treatment Facilities Providing Specified Services,by County Type, 1987

Facility locationa

Service Large metro Other metro Nonmetro

Hotline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Outreach services. . . . . . . . . . . . . . . . . . . . . . .

Early intervention services. . . . . . . . . . . . .

Employee assistance program . . . . . . . . . . . . .

Teen suicide prevention. . . . . . . . . . . . . . . . .

Self-help groups. . . . . . . . . . . . . . . . . . . . . . . .

Transportation. . . . . . . . . . . . . . . . . . . . . . . . . .

Crisis intervention. . . . . . . . . . . . . . . . . . . . .

30.7

48.2

44.7

31.1

8.3

65.7

18.8

47.7

4 2 . 6

5 3 . 4

5 1 . 4

40.0

11.7

59.5

20.3

60.3

48.4

62.8

61.1

45.6

18.0

57.9

19.8

69.8

aLarge metro = metropolitan areas of more than 100,000 residents; other metro = all other metropolitan areas;

nonmetro = all nonmetropolitan areas.

SOURCE: U.S. Department of Health and Human Services, Alcohol, Drug, and Mental Health Administration, Na-

tional Institute of Alcohol Abuse and Alcoholism, unpublished data from the National Drug and


Table 16-7—Alcohol Treatment Facilities by Client-to-Counselor Ratios and Location, 1987

Facility locationa

.

Client-to-counselor Large metro Other metro Nonmetro

ratio Number Percent Number Percent Number Percent

Inpatient. . . . . . . . . . . . . .

1-4. . . . . . . . . . . . . . . . .

5-9. . . . . . . . . . . . . . . . .

10 or greater. . . . . . .

Outpatient. . . . . . . . . . . . .

1-4. . . . . . . . . . . . . . . . .

5-9. . . . . . . . . . . . . . . . .

10 or greater. . . . . . .

2,004

518

1,088

398

2,446

4151

478

1,553

100.0

25.8

54.3

19.9

100.0

17.0

19.5

63.5

4 2 6 100.0

151 35.4

212 49.8

63 14.8

626 100.0

110 17.6

102 16.3

414 66.1

301 100.0

83 27.6

162 53.8

56 18.6

804 100.0

107 13.3

145 18.0

552 68.7

aLarge metro = metropolitan areas of more than 100,000 residents; other metro = all other metropolitan areas;

nonmetro = all nonmetropolitan areas.

SOURCE: U.S. Department of Health and Human Services, Alcohol, Drug, and Mental Health Administration, Na-

tional Institute of Alcohol Abuse and Alcoholism, unpublished data from the National Drug and


Urban and rural substance abuse treatment facili-ties have different service patterns (table 16-6)(642). While facilities in urban areas are more likelyto offer self-help groups, a larger proportion of ruralfacilities provide hotline services, outreach services,

early intervention services, teen suicide preventionservices, and crisis intervention. Compared withurban facilities, rural alcohol treatment facilitieshave slightly better counselor-to-client inpatientratios, but worse outpatient ratios (table 16-7)(642).

Rural acute-care hospitals are less likely thanequivalently sized urban hospitals to provide alcoholand chemical dependency outpatient services. Only

9 percent of all rural hospitals, compared with 20percent of urban hospitals, provide outpatient sub-stance abuse services (see table 16-4)(625).

Trends

Two notable changes in mental health serviceshave taken place since the implementation of theblock grant. First, CMHCs have tended to empha-

size services that can be billed on a fee-for-servicebasis and are covered by third-party payers (e.g.,one-on-one psychiatric therapy). A survey of 36urban and rural CMHC administrators from 8 Statesfound that they had reduced services and trainingafter the block grant went into effect; one-half hadincreased billable services and fees to cover the lossof Federal resources (185). A study examiningprogramming innovations in rural CMHCs in 12

Midwestern States concluded that the CMHC direc-tors were so concerned with billable hours andfees-for-service that the relative benefits of case-




Table 16-8-Percent of Rurala Community Mental Health Center Directors Who Expended Efforts onProgram Innovations, 1988

Effort expendedb

Program dimension Little or none Some Moderate or heavy

Rural development. . . . . . . . . . . . . . . . . . . . . . . 81 10 13

Support groups (staff facil i tated). . . . . . 7 6 1 2 1 2

Hotlin e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1 11 1 7

Media programs . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1 1 8 20

St im ula t ing se l f -he lp g roups . . . . . . . . . . . . 5 9 15 2 4

Coordinating service . . . . . . . . . . . . . . . . . . . 50 21 29

Crisis intervention. . . . . . . . . . . . . . . . . . . . . 48 20 30Consultation and education. . . . . . . . . . . . . . 28 24 47

a“Rural” mental health centers in this study woro: 1) any cen t e r s located outside a city of 50,000 or more people and outaide of a metro area,and 2) contors whoso catchment q reas included large portions outside

such areas.

hews add to less than 100 percent because some respondents did not provide data.

SOURCE: J. Mermelstein and P. Sundet, “Factora Influencing the Decision To Innovate: The Future of Community

Responsive Progranrning,” Journal of Rural Comnunity Psych- 9(2):61-75, 1988.

finding programs, such as hotlines and supportgroups, were overlooked as a potential strategy for

increasing utilization and income (383). Fewer thanone-half of CMHC directors reported expending anysignificant efforts on support groups, self-helpgroups, and crisis hotlines, and only a little morethan one-half expended any significant efforts oncrisis intervention or service coordination (table16-8).

Second, in accordance with both Federal and State

policies, CMHCs have tended to emphasize servicesfor persons with severe and persistent mental illnessat the expense of services for the less seriously orless chronically ill. Dowell and Ciarlo found thatprevention, education, and consultation serviceswere the first services to be cut after the block grantswent into effect (174). Another post-block-grantsurvey found that all three of the highest rankedpriorities of mental health program directors focused

on services for the chronically mentally ill (5).Perhaps because of this shift in emphasis, manyCMHCs were ill-equipped to deal with the increasein acute mental health problems associated with thefarm crisis of the early 1980s (383).

The shift to increased services for seriouslymentally ill patients was accomplished by an in-crease in outpatient and partial hospitalization ratherthan through an increase in residential and other

inpatient care. After adjusting for inflation, State

mental health program expenditures on communityservices increased by 10 percent between 1981 and

1985, while mental hospital expenditures decreasedby nearly 5 percent (540).

9A survey of 71 CMHC

clinical directors found that the greatest expansion inservices during 1983 and 1984 was in day treatmentand partial hospitalization (304).

Rural CMHCs in the 1970s were more dependentthan urban ones on Federal support (67), and a recentanalysis found no reason to believe that the situationhad changed (423). Whatever the trends in theirfinancial support, rural CMHCs seem to haveresponded through retrenchment rather than throughinnovation. A survey of State mental health directorssurveyed in the mid-1980s found that these directorslisted the development of model rural CMHCservices as second to last in a list of 62 priorities (5).

Other Issues

One rural service problem is the lack of awarenessamong rural residents that mental health servicesexist and can be helpful. Flaskerud and Kvizsurveyed 3,057 residents of rural counties in sixMidwestern States and found that fewer than one-half knew of available treatment centers and servicesfor mental health and substance abuse problems(193). Fehr and Tyler found that only 40 percent of rural North Dakota survey respondents knew of the

mental health clinic that served their catchment area

~nadjustedchanges inexpendituresduring this time were an increase of 50 percent on community services and an increase of 0percent onhospitaIs.These figures include both urban and rural areas.




(189). Even in communities where the clinics werelocated, only 52 percent of residents were aware of services (189).

An initiative in Illinois reported some success inimproving awareness of mental health services. ThisState program used community education, a crisishotline, and outreach workers with farm experienceto reach farm families under stress (119). Theprogram coordinators decided to operate the pro-gram separately from the local CMHCs, a featurethat initially engendered considerable opposition to

the program by some CMHC directors (119).

Transportation for both clients and professionalsis a serious rural mental health service issue.Although catchment areas are no longer used forFederal purposes, many States continue to use themfor funding and service requirements (105). Theaverage size of a rural catchment area ranges from5,000 to 17,000 square miles (depending on the

definition of rural). The Federal mandate for theseareas to comprise at least 75,000 people resulted in

such large service delivery areas in some States that

other legislative requirements for accessibility and

continuity of care became difficult to meet for many

of the most rural areas. One catchment area in

Arizona, for example, is over 60,000 square miles.

One in Montana is 50,000 square miles, and one in

Kansas covers 20 counties (13 of which have no

town with over 2,500 residents). Some rural dis-tances were so great that continuity of care and

followup services were virtually impossible to

provide.

Difficulties in obtaining mental health care confi-

dentially can also act as a barrier to services (356),

particularly for rural youth. A survey of adolescents

in a small town in the Midwest showed a preference

for specialized clinics over private physicians’

offices for particularly sensitive matters such as

contraception and substance abuse (149). Adoles-

cents also prefer not to be accompanied by parents

when they seek health care for problems like

depression (381).

Other problems for rural mental health service

delivery include communication (e.g., high tele-

phone costs), large numbers of patients who cannot

or will not pay for care, difficulty in recruiting and

retaining mental health professionals, and a lack of

suitable service models (458).

RURAL MENTAL HEALTHPERSONNEL

Mental Health Professionals

A study of professionally trained mental healthpersonnel (i.e., psychiatrists, Ph.D. psychologists,social workers, master’s level psychologists) done inthe early 1980s found that there were more countieswithout such professionals than there were countieswith at least one type of mental health professional

(1,682 v. 1,393) (figure 16-1) (324). Countieswithout mental health personnel had lower educa-tional levels and were ‘‘more rural” than those withproviders.

The uneven dispersion of mental health profes-sionals is most notable for psychiatrists.

q

q

q

q

q

Although both urban and rural areas haveexperienced recent increases in numbers of

psychiatrists, the number of non-Federal psy-chiatrists per 100,000 residents in rural areas isstill less than one-fourth the urban number (3.6v. 15.9) (table 16-9) (686).

In 1988,61 percent of all rural residents-over34 million people-lived in designated psychi-atric personnel shortage areas (665).

Staff psychiatrists are less likely to be found inrural than in urban general hospitals of all sizes

(table 16-10); over 90 percent of the Nation’s1,890 rural hospitals with fewer than 100 bedshave no psychiatrist on staff (625).

Rural residents travel for substantially longertimes to visit psychiatrists than do urbanresidents (averaging 33 v. 24 minutes, respec-tively) (644).Living in a rural area reduces an individual’sprobability of seeing a psychiatrist by more

than 30 percent (548).

Psychologists are also apparently disproportion-ately distributed between urban and rural areas,although national data are lacking. One study of psychologists who received their doctorates fromprograms supported by the NIMH between 1968 and1980 found that 11 percent were practicing incommunities of fewer than 50,000 residents (546).In contrast, of psychologists who were trained in the20 existing rural mental health programs, or whoexpressed an intention to obtain rural training, 24percent worked in small communities (546).




Figure 16-1-Geographic Distribution of Counties With at Least One Provider and With No Listed Provider

NOTE: Counties with at least one provider are shaded; those with no listed providers are unshaded.

SOURCE: D.J. Knesper, J.R.C. Wheeler, and D.J. Pagnueco, “Mental Health Serviees Providers’ Distribution Across Counties in the United States,” AmericanPsychologist 39(12): 1424-1434, Deeember 1984. Copyright 1984 by the Ameriean Psyehologieal Association. Reprinted by permission.

Master’ s-level clinical psychologists are less

numerous than Ph.D. psychologists, but they are

more evenly distributed. An extrapolation of data for

the 10 States with the largest rural populations foundthat the average number of doctoral-level psycholo-gists per 100,000 residents was 14, compared with

19.0 for the total population (571). The average

number of master’ s-level psychologists in these 10

States was 9.2 per 100,000, compared with 10.1 per100,000 for the entire United States. (Many master’s

level psychologists have a limited scope of practiceor must work under supervision. Only three States—Minnesota, Vermont, and West Virginia-permitmaster’ s-level personnel to hold licenses as inde-

pendent psychologists practicing outside the educa-

tional system (155a).)

A preliminary study of six States10

found thatsocial workers are the most widely dispersed mentalhealth practitioner group in low-income rural areasand are more likely than either psychiatrists orpsychologists to choose to practice in these areas(table 16-11) (416). In about 25 percent of all thecounties studied, social workers were the onlymental health providers. Furthermore, a substantialproportion of counties with no mental health provid-ers were contiguous with counties served only bysocial workers (416).

l q l l ~ o i s , Michigan, Oklahoma, Texas , F lo r ida , an d WestVkp.




Table 16-9-Non-Federal Psychiatrists by Metropolitan/Nonmetropolitan Location, 1975 and 1988

Rate per Percent100, 000 population change

1975 1988 1975-88

United States (total) .,. 10.0 12.9

Metro . . . . . . . . . . . . . . . . . . . 12.4 15.9

Nonm et ro . . . . . . . . . . . . . . . . 2 .6 3 .6

5 0,0 00 an d op er a . . . . . . . 3 .8 5 .6

25 ,000 - 49 ,999a . . . . . . . 2 .6 3 .1

10,000 - 24,999a . . . . . . . 1.4 1.6

Less than 1O,OOOa

. . . . . . 0.6 0.8

6+ persons/sq mib

. . . 0.5 0.8b<6 persons/sqmi . . . . 0.7 0.9

28.9

28.2

35.4

47.0

17.8

12.5

29.7

83.517.4

aIncludes only nonmetro counties.

bIncludes only nonmetro counties of fewer than 10,000

residents.


vices, Health Resources and Services Admin-

istration, Bureau of Health Professions,

unpublished data from the Area Resources

File (provided by H. Stambler, 1990).

A study of the Nebraska community mental health

workforce between 1981 and 1.988 found that ruralcenters relied heavily on master’s-level profession-als, while employees in urban centers were predomi-nately bachelor’s level and below (583). Althoughthere was a substantial decrease in rural staff duringthe period, the decrease was mostly in nonmedicalstaff; the number of full-time-equivalent medical

staff did not decrease significantly (583).

Eisenhart and Ruff visited 10 mental healthcenters and concluded that urban and rural mentalhealth professionals provide different services to

clients (182). They found that rural mental healthprofessionals had to perform a greater variety of

tasks, accept a less structured environment, deal

with more crisis situations, respond to other staff members’ needs and concerns, and develop asensitivity and commitment to the local community.In contrast, the urban mental health professional wasable to concentrate on developing specialized skills(e.g. treating behavioral disorders) and focus moreon professional issues such as publishing articlesand continuing education (182). The different styleof care required in rural communities may discour-

age psychiatrists and psychologists from choosing a

rural practice unless they are trained to contend withthe uniquely rural needs.

Isolation adversely affects recruitment and reten-tion of mental health professionals in many ruralcommunities (163,233). The isolation of some ruralmental health professionals can spawn strong inter-dependent relationships and innovative arrange-ments among colleagues. In communities withoutpsychiatrists, for example, the primary care physi-cians who must authorize the medications for theirmentally ill patients may consult with their local

psychologist colleagues--who are prohibited fromprescribing--regarding information about the medi-cations (111). In other areas, centrally based psychi-atrists may provide substantial amounts of servicesthrough telephone consultation to rural therapistsand nurses on site (247). A part-time satellite clinicstaffed by a group of nonpsychiatrist health profes-sionals with some specialty expertise (e.g., familyservices, the chronically mentally ill) proved suc-cessful in enhancing service availability and mini-mizing professional isolation in Maine (120).

Like other health professionals, rural mentalhealth professionals often must become generalists(182,234,458). They may need to develop tech-niques for community outreach, monitor personswith chronic illness, consult with teachers to helpchildren in distress, or develop training modules forstress management. Moreover, in rural areas mental

health professionals must become part of the com-munity to be effective (234). The overlap betweenpersonal and professional roles can lead to burnoutand conflicts between professional impartiality andpersonal values. For the patient, this overlap is alsoan issue because the effectiveness of mental healthtreatment is often dependent on anonymity andconfidentiality.

Pulakos and Dengerink examined the servicesprovided in State-funded rural and urban CMHCs inWashington State (497).

11They found that rural

therapists were more likely to be generalists (spend-ing time in two or more activities), while urbantherapists were more specialized. Compared withurban therapists, rural therapists spent more time insupport services (e.g., advocacy, recordkeeping) butcomparable time in indirect services (e.g., preven-

tion, consultation, education). In both rural and

IIC ‘R@’ ~d ‘cub~” Weredefmedby cowtypop~tion. Rural centers were located in 15 communities ranging inpopulationfium 2,600 to %,~

and urban centers were located in 15 communities with more than 46,000 residents.



Table 16-10-Average Number of Mental Health Professionals” in Community Hospitals, by County Type and Hospital Size, 1987

Metro NonmetroHospital size Social Social

(number of beds) Psychiatrists Psychologists workers b Totalc

Psychiatrists Psychologists workers b Totalc

6-24. . . . . . . . . . . . . 0.3 0.0 0.1 0.4 0.0 0.0 0.1 0.1

25-49. . . . . . . . . . . . 0.6 0.0 0.3 0.9 0.1 0.0 0.3 0.3

50-99. . . . . . . . . . . . 1.0 0.1 0.7 1.8 0.2 0.0 0.7 0.9

100-199. . . . . . . . . . 3.0 0.3 2.0 5.3 0.8 0.1 1.4 2.3

200-299. . . . . . . . . . 6.3 0.4 4.2 11.0 2.3 0.2 2.8 5.3

T o t a l . . . . . . . , . . 3 . 4 0.3 2.2 5.9 0.4 0.0 0.8 1.2

(<300 beds)

aInclude~ both full-time and part-time personnel (not full-time e~ivalents; part-time staff are weighted the same as full-time staff).Figures for psychiatrists are for full-time staff only.

bSocial workers may hold positions not associated with the provision of mental health services (e.g., discharge planning).cTotal includes all full-time psychiatrists and all full- and part-time psychologists and social workers.

SOURCE: Office of Technology Assessment, 1989. Data from American Hospital Association’s 1987 Survey of Hospitals.




Table 16-11—Percent of Counties Served by Mental Health Providers in Six States

Psychiatrist, Psychologist

psychologist and and social SocialOther

State social worker worker only worker only combination None

Illinois . . . . . . . . . . . . . . . 29 19 33 13 6 Michigan. . . . . . . . . . . . . . . 43 27 28 1 1Oklahoma . . . . . . . . . . . . . . . 18 14 34 30 4Texas . . . . . . . . . . . . . . . . . . 19 10 26 40 3Florida . . . . . . . . . . . . . . . . 52 9 5 16 18

West Virginia . . . . . . . . . . 37 35 26 4 6

a primarily psychiatrist and social worker.

SOURCE: National Center for Social Policy and Practice,“Report of the Geographic Distribution of Mental

Health Providers: A Pilot Study,” unpublished manuscript, Silver Spring, MD, July 1982.

urban communities, individual psychotherapy wasthe direct service most frequently provided, andfamily and group therapy were provided at roughlythe same level across communities (497),

No single office at NIMH has responsibility formental health personnel issues. The Health Re-sources and Services Administration (HRSA) has

the administrative capability to identify mentalhealth shortage area designations, but national datasources describing nonpsychiatric mental healthProfessionals and the locations of their practices arenot available (except for professionals who work inspecialized mental health facilities).

Other Rural Mental Health Providers

Primary Care PhysiciansMental and physical health care systems are

interdependent in both rural and urban areas. Pri-mary medical care is an important part of mentalhealth service delivery because primary care physi-cians and clinics are the frost contact in the caresystem for many patients, they often assume long-term responsibility for the care of their patients, andthey can help to integrate services for the patient (2).

Only 19 percent of respondents to a survey of ruralNorth Dakota residents listed mental health servicesas their first choice for treatment for “mental,nervous, or emotional problems,’’ while physicianswere ranked as the first choice by 50 percent of therespondents (189). For seriously mentally ill pa-tients on long-term drug therapy in rural areas,primary care physicians may be the only personsavailable who can authorize the needed prescrip-

tions and monitor patients’ progress.

In fact, four times as many people are treated formental health disorders by primary caregivers as are

treated by mental health specialists (10,503). Morespecifically, in 1984:

q

q

q

q

q

q

Nonpsychiatrist physicians provided almostone-half (48 percent) of the patient visitsresulting in the diagnosis of a mental disorder.General practitioners, family practitioners, andinternists accounted for over three-fourths (77

percent) of these diagnoses.Primary care physicians referred these patientsto a mental health professional in only 5 percentof the episodes.About 85 percent of all psychoactive drugprescriptions were made by nonpsychiatrists.Over one-fourth (28 percent) of nonpsychiatristvisits were for psychological problems.Anxiety and nervousness accounted for 11

percent of the reasons people visited a physi-cian (655).

These numbers are not specific to rural areas,where the relative lack of mental health profession-als in rural areas may lead to particularly heavydependence on primary care physicians as sources of mental health care. Only 5 percent of visits topsychiatrists occur in rural areas. In contrast, 30

percent of all visits to physicians by patients withpsychiatric diagnoses are made in rural areas, as are16 percent of the physician visits that include somepsychotherapy (655). Clearly, rural nonpsychiatricphysicians are providing substantial amounts of mental health care.

Allied Mental Health Professionals,Paraprofessionals, and Volunteers

Members of the clergy are professionals who areparticularly important providers of some rural men-tal health services. In the North Dakota survey, 45




percent of respondents listed the clergy as their frostchoice of help for “family problems” (189).

Local paraprofessionals with no formal academicmental health training can fill some of the gaps inrural mental health provision. These individualsreceive training and consultation from mental healthprofessionals on topics such as crisis management,case identification, and community education. D’Augellisuggests that paraprofessionals can increase com-munity awareness and acceptance of mental healthservices and promote mental health through such

mechanisms as conducting training in “life skills”(e.g., parenting), developing self-help groups, andstrengthening natural helping systems (informalnetworks of community residents) (160). They canalso identify new cases and act as liaisons betweenprofessionals and the community.

Crisis intervention is one area where trainedvolunteers can sometimes provide important first-level help. Volunteers may bean especially critical

component of crisis services both in remote areas notserved by a local mental health professional and inareas where a 24-hour on-call professional wouldrequire a long-distance telephone call or extensivetravel.

Helping community members to help each otheris another approach that has been successfullyadapted to rural areas. In one example, mental health

professionals in a CMHC in northwestern Iowadeveloped support groups and a peer listeningprogram for farmers and their families (3). Thecommunity response was so overwhelming that theCMHC started support groups in satellite clinics andreported a tenfold increase in the utilization of itsservices.

Mutual- and self-help groups that focus on acommon medical or mental health problem are

another approach for including local residents inmental health care. These groups, which have growndramatically in popularity over the past decade,provide residents with the opportunity to help eachother cope with stress, solve problems, develop asense of belonging, share knowledge and experi-ences, and educate themselves about medical alter-natives (229344,638).

Training for Rural Mental Health Personnel

Fewer than one-third of mental health trainingprograms place any emphasis on rural training and

placement (546,560). Exemplary programs do exist.Liechtenstein et al. describe the development of al-year training program designed to provide out-

reach services (consultation, education, and commu-nity organizational development) in two rural com-munities (351). Students in the program reportedmoderate skill acquisition and positive communityresponse. Bergstrom et al. describe another ruralmental health training program that included apracticum in rural consultation and education (84).A mental health Area Health Education Center inNorth Carolina reports success in developing contin-

uing education programs for rural professionals andfacilitating linkages between rural mental healthgeneralists and central specialists (227).

Rural-oriented training seems to affect the likeli-hood that graduates will practice in rural areas,although information is scarce. A study of graduatesof psychology training programs supported byNIMH between 1968 and 1980 identified two

rural-oriented programs training master’ s-level psy-chologists (546). Of the 66 identified graduates of these programs, 42 were practicing in small towns orrural areas. This study also found that master’ s-levelstudents were more likely than doctoral-level stu-dents to remain in the State of their training (546).

Recent legislation (Public Law 100-607) ex-panded Federal support for faculty and curriculum

development for health professions training pro-grams, including graduate clinical psychology pro-g r a m s . Since the support applies only to doctoral-level training programs, and there are no provisionsfor targeting funding to rural-oriented projects, thisprovision may have little effect on the availability of psychologists in rural areas. However, the legisla-tion also extended the Federal loan repaymentprogram to allied health professionals, including

clinical psychologists, who practice in rural areas.A short-term continuing education program for

rural practitioners (not to exceed 5 days) wasintroduced in 1988 and is administered b y N I M H .This Depression Awareness, Recognition, and Treat-ment program targets rural and agricultural areasaffected by the farm crisis and was designed toprovide current information on the recognition,diagnosis, and treatment of depressive disorders to

the general public, mental health professionals, andprimary care physicians (639). Programs in medi-cine, psychology, nursing, and social work areeligible for funding.




Primary care physicians receive limited training

in mental health issues. For example, the 6-week

clerkship in psychiatry for all third-year students is

the briefest among the five standard third-yearclinical rounds (587). Medical students’ coursework in behavioral sciences is similarly limited, amount-

ing to approximately 5 percent of the medical

college class curriculum (587). Limited training mayexplain why primary care physicians are less ablethan mental health professionals to diagnose mentaldisorders accurately (47). Under the Health Profes-sions Educational Assistance Act of 1976 (public

Law 94-484), NIMH operated several initiatives topromote mental health training for primary care

physicians (547). However, the Act and the program

expired in 1980.

MENTAL AND PHYSICAL

HEALTH LINKAGES

The notion of linking physical and mental health

care is not new, but it may be especially useful inrural areas because of limited resources (e.g.,

personnel, buildings, funding) and services. Link-

ages may also help to reduce the stigma associatedwith the mental health system. Possible models

include:

a contractual agreement between providers for

referral and information exchange,

a mental health staff person in a health center toprovide screening and information to patients,

a mental health unit in a health center to provide

direct services,

a mental health professional in the health care

setting to consult with physicians and other

health professionals and to provide direct

mental health services,

a “linkage worker” to advise primary care

health personnel on patients with mental healthproblems (but provide no direct services to

patients), and

provision of comprehensive care with themental health and health professionals working

together on each case (476).

An evaluation of several linkage efforts of the

1970s concluded that internal organizational teams

and linkage agreements between organizations were

the most successful (104). In these efforts, themental health professionals consulted with health

center staff about their patients, provided inservice

training to the health center staff, provided emer-

gency services to health center patients, evaluatedhealth center patients for psychiatric problems,

provided short-term psychotherapy, and referred

patients. Linkage workers were usually psycholo-gists (41 percent) or social workers (38 percent).

Most of the linkage workers’ time was spent in the

primary care setting, with 27 hours per week devoted

to consulting with primary care professionals; pa-

tient evaluation and therapy were the services most

frequently provided. The linkages resulted in several

organizational changes, including increased interac-

tion among clinical, administrative, and board staff,

joint recordkeeping, and shared administrative serv-ices. Linkages appeared strongest where there wasshared administrative control between the mental

and physical health care providers and where the

linkage worker spent equal time across primary care

and mental health settings (104).

The motivations for implementing linkage pro-

grams differed between rural and urban areas. Rural

health center directors implemented programs pri-marily in order to provide direct treatment and

consultation; only 17 percent reported that establish-ing a mechanism to refer patients to the CMHC wasthe most important factor. In contrast, 43 percent of

urban health center directors listed referral opportu-

nities as the primary motivating factor (114).

Broskowski found that the most common linkage

benefits reported by agency directors were:q

q

q

q

q

q

increased awareness and detection of mental

health problems by primary care providers,

more appropriate utilization of health and

mental health services,

increased access to mental health services,

especially for the hard to reach populations

(e.g., elderly, minorities, and the poor),

reduced waiting for primary care patients andreduced burden of primary care staff,

improved information and records exchange,and

better continuity of care (104).

Few problems were reported, and most reportedwere eventually solved. They included difficulties inrecruiting qualified linkage staff, providing ade-

quate space for the linkage worker, and developingadequate transportation between sites for referrals.Problems of space and transportation were more

common in rural than in urban programs (114).




The threat of losing autonomy and interdiscipli-nary and organizational rivalries are major barriersto linkages (104,706). Arguments often revolve

around who gets reimbursed, who controls the tasksfor the linkage worker, and who controls policy for

the linkage agreement (104,121). Steps to overcome

these barriers include technical assistance and train-ing for the linkage worker and for directors, and

increasing the awareness of health and mental health

officials of their role in facilitating (or hindering)

linkage initiatives (104).

Several apparently successful examples of link-

age agreements are found in the literature (98,407,

484,637), and such agreements are a component of

some of the Rural Mental Health Demonstrations

(see box 16-A). In one case study, Boydston

described the efforts of a social worker working with

local physicians to provide mental health services

(98). The researcher concluded that collaboration

resulted in better case detection, smoothed transi-tions between the physical and mental health care

systems, and improved client attitudes about mental

health treatment. In this case, the physicians came to

value the mental health services because they

allowed the physicians more time to treat physical

problems (98).

A recent informal survey of 20 rural States found

that none have instituted any program incentives forhealth and mental health linkages, although all of

them expressed interest (171).

CONCLUSIONS

The prevalence of mental disorders in rural

Americans is similar to that of their urban counter-

parts. The services available to rural residents are

usually more limited, however, both in number and

in scope, and those that do exist are generally

provided by nonpsychiatric professionals. Psychia-trists are entirely absent in most rural communities.

Because alternative sources of mental health

services are scarce, rural mental health facilities and

personnel may be torn between the competingdemands for services to chronically mentally illindividuals and services to individuals experiencing

temporary distress or less debilitating problems.

Innovative approaches (e.g., expanding the Commu-

nity Support Program to include more rural deliverymodels) deserve investigation for both populations.Such approaches must build on the professionals and

paraprofessionals available. Models that incorporate

the use of primary care physicians, volunteers, andparaprofessionals may be particularly appropriatebecause of the scarcity of mental health profession-

als.

Federal and State funding of services such as

prevention, education, and consultation are espe-

cially important to rural areas, because these serv-ices are not reimbursable by most payers and there

may be no private sources of such services. Inmost

States, it appears that service requirements for

CMHCs have been reduced to those likely to

produce revenue (e.g., psychotherapy, partial hospi-talization), while funding for preventive services,

consultation with other health and human service

professionals, public education, and evaluation have

been reduced. Funding of rural mental health in

general also may have been reduced, but the lack of

data precludes a firm conclusion. In fact, since the

implementation of the block grant there has been

insufficient data to support any significant evalua-

tion of Federal rural mental health funding efforts.

Rural mental health professionals face problems

similar to those encountered by other health profes-

sionals. They have fewer practice-specific training

programs, fewer colleagues with whom to discussprofessional issues, and more diverse demands on

their time than do their urban counterparts. Rural

mental health professionals are also isolated in many

ways. They often lack the opportunity to discusscases with other professionals, must make decisions

alone, and lack opportunities for supervision or

mentoring. Primary care physicians, who provide

much rural mental health care, receive relatively

little training in mental health diagnosis and treat-

ment.

The lack of psychiatrists and doctoral-level psy-

chologists in rural areas, the proportion of mentalhealth care provided by nonpsychiatric physicians,

and the need to provide mental health services in

ways and settings acceptable to rural residents all

suggest that integrating mental health and otherhealth care is especially important in rural areas.

Linkages between the physical and mental health

systems that are provided by social workers, psy-

chologists, and paraprofessionals play an important

role in extending mental health services. Unfortu-nately, Federal stimulation of linkage efforts has

waned since the implementation of the mental health

block grant in 1981.




Despite the apparent success of the short-lived to such measures as changes in inappropriate utiliza-

Federal linkage program, no evaluation of the tion of social and health care services and the most

ultimate effectiveness of the program was under- effective interorganizational linkage models for

taken. Renewed efforts could include more attention different rural environments (537).



Appendixes

Appendix A

Method of the Study



y

This assessment was prompted by congressional con-cern about the state of rural health care as the 1980s drewto a close. Reported high rates of rural hospital closures,difficulty recruiting health professionals to rural settings,and concern about the future competitiveness and finan-cial viability of rural providers were contributing issues inthe request for this study.

In April of 1988, the Senate Rural Health Caucus askedthat the Office of Technology Assessment (OTA) under-

take a broad assessment of rural health care that wouldinclude, but not be limited to:

q

q

q

q

a discussion of criteria to identify or measurerurality,an overview of rural health and identification of ruralhealth trends,a discussion of the place of new health technologiesin the rural health care system, andan assessment of educational and information needs

of r u r a l health professionals and factors that affectthese professionals’ decisions to locate in rural areas.

Members of the Caucus signing the request letter includeda member of OTA’s Technology Assessment Board, theSenate Minority Leader, the Chairman of the SenateCommittee on Environment and Public Works, and the

.Chairman of the Senate Select Committee on IndianAffairs. In May 1988, a letter reiterating these concernsand supporting the request was received from the ranking

minority member of the Senate Committee on Labor andHuman Resources.

The proposed assessment was approved by the Technol-ogy Assessment Board on June 21, 1988 and began inAugust of that year. During the early part of the project,OTA staff consulted with consumer and professionalorganizations, Federal and State agency personnel, healthservices researchers, independent health professionals,and other interested individuals in order to identify criticalissues and garner suggestions for candidates for thestudy’s advisory panel. The advisory panels for 0111studies guide OTA staff in selecting material and issuesto consider and review the written work of the staff, butthe panels are not responsible for the content of finalreports.

The advisory panel for this assessment consisted of 20members with expertise in, or important perspectives on,rural hospital and clinic administration, rural medical andnursing practice, rural health services research, State

health system planning and administration, rural eco-nomic development, grants assistance, and health profes-sions education. The panel, chaired by James Bernstein of the North Carolina Department of Human Resources, met

for the first time on October 28,1988. At this meeting thepanel discussed some background materials, suggestedand reviewed plans for the project, and identified someimportant issue areas to be included in the study.

As a core component of the study, project staff heldthree field workshops to discuss specific rural healthtopics and to hear presentations on these topics from localand regional health practitioners, administrators, andofficials. The meetings were organized by the National

Rural Health Association under contract to OTA. The firstof these meetings, on rural hospitals, was held on Jan. 11,1989, in Scottsdale, Arizona. The second, on healthpersonnel issues (with special emphasis on the needs of “frontier” areas) was held on Feb. 28,1989 in Bismarck,North Dakota. The third, addressing health care issues inrural areas of heavy poverty, was held on June 15, 1989in Meridian, Mississippi. A briefsummary of the invitedparticipants and presentations at these meetings is found

in appendix G.During the course of the assessment, OTA conducted

two separate surveys of States to identify the level andscope of their rural health activities. The first survey,conducted in spring of 1988, provided an overview of State activities related to rural health and priorities andproblem areas as identified by State personnel. All 50States responded to this survey. The second survey,conducted in the summer of 1989, focused specifically onState activities and experiences regarding the designationof health personnel shortage areas and medically under-served areas. Forty-five of the 50 States returned thissurvey. The methods, instruments, and respondents forthese surveys are presented in appendix D. Survey resultsare presented in chapters 4, 11, 12, and 13, depending onthe topic addressed by the survey question.

In addition to the field workshops and surveys, OTAconducted site visits, literature reviews, and extensiveconversations with State officials and rural health profes-sionals. Data collection was an important part of thisassessment, and a substantial amount of information wasderived from data supplied by a variety of individuals andorganizations. Many of the data were previously unpub-lished, and the cooperation of these individuals andorganizations was tremendously helpful to OTA. OTAalso purchased from the American Hospital Associationthe results of its 1987 Survey of Hospitals and analyzedthese data in-house. Appendix C summarizes some

technical and definitional issues related to that analysis.A preliminary draft of the report was reviewed by the

advisory panel and discussed by panel members at thesecond and last meeting of the panel on January 26,1990.

2 0 - 8 1 0 0 - 9 0 - 1 5 Q L 3437–


S b l i d d f i h i i i i i f h d h f



Subsequently, a revised draft was sent, either in part or inwhole, to more than 150 Federal and State officials,representatives of interested parties, and other experts fortheir review and comment. The final draft, incorporatingrevisions based on reviewers’ comments, was transmittedto the Technology Assessment Board in late March 1990.

In addition to the main report, this assessment of ruralhealth care included two other publications. The staff

commissioning of the papers and the expenses of workshop participants. A summary of this report iscontained in appendix H.

Background papers commissioned by OTA during thecourse of the assessments of Health Care in Rural

America and Rural Emergency Medical Services arelisted below.

1Tom Hoffman of Washington, DC indexed

the reportpaper, Defining ‘

( Rural” Areas: Impact on Health Care

Policy and Research, was released in July 1989 and q

discussed the health care policy implications and uses of various alternative ways of defining rural areas and q

populations. The Special Report, Rural Emergency Medi-

cal Services, released in November 1989, was written by q

OTA staff based on background papers, a workshop, andadditional sources of information. The Department of q

Transportation provided financial support for both the

.

J. Chin, “Rural Emergency Medical Services: AReview of the Literature,” April 1989.M.I. Dube, “The Legal Environment Affecting theDelivery of Rural Health Care,” July 1989.

L.J. Shuman and H. Wolfe, “Ruralism: A Model forRural EMS Systems Planning,” July 1989.D.G. Stamper, “Status of Air Medical TransportSystems,” May 1989.

IAII papers were prepared under co n t rac t t o O’IA. I $UMI@ for the three background papa - s r e l a t i n s t o e r n e r I J e n c Y r n e d k d *c% h ~~, vwus

provided by the U.S. Department of Tr aqm t d i on .

Appendix B

Acknowledgments



This report was greatly aided by the contributions of many individuals. OTA staff extend special thanks to the manypeople who took the time to provide information, respond to surveys, and participate in field workshops. In addition, OTAwould like to thank the following individuals for their assistance. (This acknowledgment should not be construed to implythat the individuals either endorse or disagree with the conclusions of the report.)

Charles AlferoAlbuquerque, NM

Nancy BarrandThe Robert Wood Johnson Foundation

Princeton, NJ

Peter BeesonOffice of the GovernorLincoln, NE

Viola BehnNew York State Department of HealthAlbany, NY

Suzette Berm

Connecticut Department of HealthHartford, CT

Sylvia BoederAmerican Hospital AssociationChicago, IL

Cathy BoelkeWisconsin Department of Health and Social ServicesMadison, WI

John BondsNew Hampshire Division of Public Health ServicesConcord, NH

Jennifer BoulangerProspective Payment Assessment CommissionWashington, DC

Diane BowenIdaho Department of Health and WelfareBoise, ID

Sharon CagenRhode Island Department of HealthProvidence, RI

Michelle CaseyMinnesota Department of HealthMinneapolis, MN

Don CoffeyDepartment for Health Services

Frankfort, KYTim CondonAlcohol, Drug Abuse, and Mental Health AssociationRockville, MD

Jerry CoopeyOffice of Rural Health PolicyRockville, MD

Philip Cotterill

Health Care Financing AssociationBaltimore, MD

Roger C. CourtneyAmerican Association of Colleges of Osteopathic

MedicineWashington, DC

Ellen K. CromleyUniversity of ConnecticutStorrs, CT

Jake CulpOffice of Rural Health PolicyRockville, MD

Marcia DaigleDHH Primary Care ProjectBaton Rouge, LA

Division of National Health Service CorpsRockville, MD

Lee DixonIntergovernmental Health Policy ProjectWashington, DC

Jean DufresneOffice of Inspector GeneralDepartment of Health and Human ServicesAtlanta, GA

Gar ElisonUtah Department of Health

Salt Lake City, UTKaren ErdmanNational Alliance for the Mentally IllArlington, VA

Curtis EricksonGreat Plains Health Alliance, Inc.Phillipsburg, KS

Bill Finerfrock American Academy of Physician Assistants

Alexandria, VAJack GellerUniversity of North Dakota School of MedicineGrand Forks, ND

-439-


Gregory Glass Jeanette Klemczack



Gregory GlassFlorida State Health OfficeTallahassee, FL

Sophie Glidden Maine Department of HumanServices

Augusta, ME

Gary Goubeau

Bureau of Health Care Delivery and Assistance

Rockville, MD

Helen Grace

W.K. Kellogg FoundationBattle Creek, MI

Holly GrasonAssociation of Maternal and Child Health ProgramsWashington, DC

J. Patrick HartNorth Central Wisconsin Office of Rural HealthWausau, WI

Herman HeinThe University of Iowa Hospitals and ClinicsIowa City, IA

Chris HoganPhysician Payment Review CommissionWashington, DC

Hospital Data CenterAmerican Hospital AssociationChicago, IL

Alison HughesUniversity of Arizona

Tucson, AZDana HughesBerkeley, CA

Jeff Humanoffice of Rural Health PolicyRockville, MD

Charles HuntingtonAmerican Academy of Family PhysiciansWashington, DC

Ernesto IglesiasCalifornia Department of HealthSacramento, CA

Wilma JohnsonBureau of Health ProfessionsRockville, MD

Wilbert L. JonesGreater Meridian Health ClinicMeridian, MS

Sherry KaimanNational Rural Health AssociationWashington, DC

Jeanette Klemczack Michigan Department of Public HealthLansing, MI

Ken Kochanek National Center for Health StatisticsHyattsville, MD

Ann KoontzBureau of Maternal and Child Health and Resource

DevelopmentRockville, MD

Yvette LambArkansas Department of Health

Little Rock, ARRichard C. LeeBureau of Health ProfessionsRockville, MD

Harvey LichtDepartment of Health and EnvironmentSanta Fe, NM

Diane Makuc

National Center for Health StatisticsHyattsville, MD

Keith McCartyMontana Hospital Research and Education FoundationHelena, MT

Joan McConnelAlabama Department of Public HealthMontgomery, AL

Steven McDowellOffice of Rural HealthTopeka, KS

Dick MerrittIntergovernmental Health Policy ProjectWashington, DC

Carole MillerMountain ManagementOjo Sarco, NM

Evelyn MosesBureau of Health ProfessionsRockville, MD

Hermoz MovassaghiIthaca CollegeIthaca, NY

Lindy NelsonColorado Department of HealthDenver, CO

Andrew W. NicholsUniversity of ArizonaTucson, Az

Appendix B--Acknowledgments .441

Greg Nycz Elsie Sullivan



Greg NyczMarshfield Medical Research FoundationMarshfield, WI

Lucy OzarinBethesda, MD

David PalmNebraska Office of Rural HealthLincoln, NE

Larry PattonAgency for Health Care Policy and ResearchRockville, MD

Richard Penna

American Association of Colleges of PharmacyAlexandria, VA

Dawn PhilibertHealth Policy CouncilWaterbury, VT

Luci PhillipsWashington Department of HealthOlympia, WA

Dena Puskin

Office of Rural Health PolicyRockville, MD

Steve RosenbergRosenberg and AssociatesBolinas, CA

Michael SamuelsUniversity of South CarolinaColumbia, SC

Rachael Schwartz

National Perinatal Information CenterProvidence, RI

Peter ShaughnessyUniversity of Colorado Health Sciences CenterDenver, CO

Bernard SimmonsSouthwest Health Agency for Rural PeopleTylertown, MS

Tim SizeRural Wisconsin Hospital CooperativeSauk City, WI

Howard StamblerBureau of Health ProfessionsRockville, MD

Joel SuldanMcDermott, Will, & EmeryWashington, DC

Elsie SullivanBureau of Health Care Delivery and AssistanceRockville, MD

Ella TardyMississippi State Department of HealthJackson, MS

Mary ThompsonUtah Department of HealthSalt Lake City, UT

Jan TowersAmerican Academy of Nurse PractitionersLowell, MA

Elisha TylerU.S. Public Health Service Recruitment ProjectMcLean, VA

MaryUyedaNational Association of CountiesWashington, DC

Bob Van Hook

National Rural Health AssociationKansas City, MO

Morton WagenfeldWestern Michigan UniversityKalamazoo, MI

Susan WalterMartinsburg, WV

Cathy Wasem

Office of Rural Health PolicyRockville, MD

Elizabeth WennarU.S. General Accounting OfficeWashington, DC

Jerri WestonAgency for Health Care Policy and ResearchRockville, MD

Lou WienckowskiRockville, MD

Donna WilliamsNational Rural Health AssociationKansas City, MO

Sidney M. WolfePublic Citizen Health Research GroupWashington, DC

Appendix C

Definitions of Hospitals in OTA Analyses of 1987American Hospital Association Survey Data



American Hospital Association Survey Data

Community hospitals included in the OTA analyses aredefined as all non-Federal

1, generally short stay (less than

30 days), nonspecialty hospitals responding to the Ameri-can Hospital Association (AHA) 1987 annual survey of U.S. hospitals. (Community hospitals with long-term careunits having patient stays longer than 30 days areincluded). This definition differs slightly from AHA’sdefinition of community hospitals, which also includes

non-Federal, short-stay specialty hospitals.

Federally designated sole community hospitals (SCHs)and rural referral centers (RRCs) are those identified asexisting in 1987 or later, according to lists provided by theHealth Care Financing Administration (HCFA) that werematched with the list of community hospitals in the OTAanalyses. The OTA analyses do not include everydesignated SCH and RRC, as in some cases hospitalnames of lists supplied by HCFA do not correspond to the

names of hospitals available from the AHA data file. Thismay be due to name changes as a result of reorganization,buyouts, transfers of ownership, or other factors. The lists

Table C-l—Data on the Number of Sole CommunityHospitals (SCHs) and Rural Referral Centers (RRCs),

1987

SCHs RRCs

Number on HCFA list . . . . . . . . . . . 367 229Number identified in AHA dataa . . 313 217Difference (%) . . . . . . . . . . . . . . . . . .54(14.7%) 12 (5.2%)

Wffice of Technology Assessment analyses are based on these figures.


may also include hospitals that have closed. The data onslippage are presented in table C-1.

The 277 community hospitals included in the OTAanalyses that are defined as frontier are those located incounties with population densities with 6 or fewer personsper square mile. The list of 387 frontier counties was

tabulated from 1985-86 county population estimatesbased on the 1980 census and was supplied by theNational Association of Counties in Washington, DC.

-442-

Appendix D

Background Material for Two OTA Surveys



Methods

OTA’S 1988 Survey of State

Rural Health Activities

Survey Instrument and Respondents—A writtenquestionnaire was designed to assess State involve-ment in rural health programs and activities (a copyof the questionnaire and a list of respondents’ namesand addresses follow the methods section in thisappendix). A draft of the survey instrument wasreviewed by selected individuals and by two of theeventual respondents, and it was subsequently re-vised in accordance with their comments.

Respondents for the survey were identifiedthrough brief telephone interviews with State healthofficers or other individuals known to be knowl-edgeable about rural health activities within that

State. Multiple responses were received from 13States where 2 or more organizationally independententities were identified as playing a major role inState rural health planning, development, research,and/or policy (see ch. 4, figure 4-l). A total of 65respondents reported for the 50 States.

The survey solicited basic descriptive informationincluding the agency’s specific rural health objec-tives, location in the State organizational structure,and origins (e.g., legislative or administrative).

Respondents were asked to indicate whether theyhad been directly involved during the past 3 years inspecific rural health activities within the following8 general categories:

1.

2.3.

4.5.

6.

provider recruitment/placement;financial assistance to local organizations;technical assistance to rural communities,health facilities, and health providers;rural health research;rural health systems coordination and implementa-tion;education;

7. legislative affairs relating to rural health; and8. rural health-related publications.

Respondents were then asked to identify, from theeight general activity categories, the three that weretheir organization’s highest priorities for action, andto indicate any special populations (e.g., children,elderly, low income, racial/ethnic groups) to whichtheir previously identified rural health activities

were targeted. Respondents were asked to rank sixgeneral health issue areas (e.g., medical liabilityinsurance costs/availability, payment issues, healthprovider issues) according to which were the mostpressing issues for rural health in the State, with theoption to add and rank any of their own priorities notlisted. Respondents were also asked to rate on asix-point scale their level of involvement in severalspecific health services (e.g., acute health care, child

health care, long-term care, mental health care). Dueto inconsistencies in interpretation of and responsesto this section

l, however, responses were not in-

cluded in the analysis.

Data Collection and Analysis—Data were col-lected on the mailed survey form from all 50 States.After being received by OTA, the data were summa-rized on a standardized form and sent back to the

respondent for verification. For States with morethan one respondent, all respondents were sent botha copy of their response summary and the summariesfrom the other respondents in their State. Theverified (or corrected) data were used for theanalysis. Information about budget and staff sizewas also collected, but because these items were notaddressed consistently

,budget and staff data were

for the most part excluded from analysis. While

specific budget data were not comparable, analysisof funding sources was conducted to examine thedegrees of dependence of responding organizationson Federal, State, and private or other dollars. Forthis reason, only budget changes and sources arereported.

IFOllOWUp phone conver s a t ions w ith r es ponden t s revealed that many thought this section of tie survey meant to elicit responses regarding level of involvement in the delivery of these specific services, rather than involvement in m - planning, and development activities.

?D i f f e r e n c e s in S ta te b u d g e ? i . n g and recording procedures as well as dif ferences in S tates ’ def ini t ions of “rural” l imited the amount and uniformity

of fmcial data collected through the sumey. Seven States did not respond to this section of the survey, and the remaihg 43 used a variety of methodsto determine the amount of their budget spent on rural health activities. Some respondents listed the entire Statehea l th budge t o the r s compu ted the ru r a l

h e a l t h budge t a s a pe rcentage of the to ta l S ta te hea l th budge t according to the propor t ion of rura l r e s idents or rura l count ie s in the S ta te ; and some Statesreported specific budget allocations for rural health initiatives.

443–



Appendix D--Background Material for Two OTA Surveys q 445

questionnaire. Forty-five of fifty States returned q if States had sufficient resources to monitor



questionnaire. Forty five of fifty States returnedquestionnaires—a 90 percent response rate.

7(No list

of respondents to this survey is included in this

appendix because some responses were confiden-tial.) q

The goals of OTA’s survey were to learn:

q

q

q

how satisfied States were with Federal designa-

if States had sufficient resources to monitor

health personnel shortage and medically un-

deserved areas; and

what Federal programs were perceived to have

had the most positive effects on shortage and

underserved areas.

tion criteria and processes;if and why interest in Federal designations had

Data analysis included variable frequencies and

increased or decreased over the last 5 years;some regional comparisons.

if States were using their own health personnel

shortage areas or medically underserved areadesignations and, if so, how they were used;

7(-~o~ c o ~ t i c u ~ 10~k Ch~tt s,~ NOrthDakotadidnot returnqutxtio*s. Wyoming wasaLw excludedfromthe Survey amlysisbeeause, as of June 1988, the position responsible for HMSA/MUA designations was eutand it has since been left to individual counties and hospitals

to do their own designations.


List of Respondents to OTA’s 1988 Survey of State Rural Health Activities



NOTE: The first respondent listed under each State was the “primary respondent”, whose responses to the ranking andrating sections were used to express State rural health issues and priorities.

‘‘*’ indicates the entity whose activities are reported in the survey response. Budget data may not be reported for the sameentity, but for a more specific division.

‘‘**’ indicates the person who completed the questionnaire.

Joan McConnellDirectorPlanning and Program DevelopmentBureau of Environment& Health Service

Standards

Dept. of Public Health434 N. Monroe Street Room 249Montgomery, AL 36130-1701* Bureau of Environment & Health Service

Standards** Naomi Halverson

Dwayne B. PeeplesDivision of Public HealthDept. of Health& Social ServicesP.O. Box H-06Juneau, AK 99801* Division of Public Health,Dept. of Health and Social Services** Dwayne B. Peeples

Alison M. HughesAssociate DirectorRural Health OfficeUniversity of Arizona3131 East Second StreetTucson, AZ 85716* Rural Health Office

** Alison M. Hughes

Charles McGrewDirectorSection of Health Facilities, Services&

systemsArkansas Dept. of Health4815 W. MarkhamLittle Reek, AR 72205* Section of Health Facilities, Services &

systems

** Yvette Lamb, Director,Office of Primary care

Charles CranfordDirectorArkansas Area Health Education Center

ProgramUniversity of Arkansas for Medical

Sciences4301 W. Markham, Slot 599Little Rock, AR 72205

* AR Area Health Education CenterProgram** James L. McFadin, Associate Director,Administration

William AvrittChief Rural and Community Health DivisionDept. of Health Services714 P street

Sacramento, CA 95814* Rural and Community Health Division** Lawrence J. McCabe, Jr., Chief,Hospital and Medical Standards Program

Margaret GerouldDeputy DirectorDivision of Health Planning and AnalysisOffice of Statewide Health Planning&

Development1600 9th Street, Room 440

Sacramento, CA 95814* Office of State Health Planning &Development

** Ernesto Iglesias, Manager, Small &Rural Hospital Project

Lindy WallaceHealth Planning ConsultantColorado Dept. of Health4210 E, 11th AvenueDenver, CO 80220

* State of Colorado** Lindy Wallace

Susette BennCenter for Chronic Diseases/Urban/Rural

Health150 Washington StreetHartford, CT 06106* State of Connecticut** Susette Benn

Richard SteimanDeputy DirectorDivision of Public HealthCooper Bldg, P.0. Box 637Dover, DE 19903* Division of Public Health** Marihelen Barrett, MCH Director

Gregory GlassAdministratorFlorida Health Manpower Program

1317 Winewood BoulevardTallahassee, FL 32399-0700* State of Florida** Gregory Glass

Raymond SeaboltDirectorPrimary Health Care SectionRoom 100878 Peachtree Street, N.E.Atlanta, GA 30309* Primary Health Care Section** Rita C. Salain, Community Health

Specialist

David Foulk DirectorCenter for Rural HealthGeorgia Southern CollegeL.B. #8148Statesboro, GA 30460* Center for Rural Health, Georgia

Southern College** David Foulk

Peter SybinskyDeputy Director for Planning, Legislation

and OperationsHawaii Dept. of HealthP.O. BOX 3378Honolulu, HI 96801* Dept. of Health** Peter Sybinsky

Diane BowenSupervisorOffice of Health Policy& Resource

DevelopmentDivision of HealthDept. of Health& Welfare450 W. State Street, 4th FloorBoise, ID 83720* State of Idaho** Diane Bowen

Alvin B. GrantActing DirectorCenter for Rural HealthIllinois Dept. of Public Health535 West JeffersonSpringfield, IL 62761* State of Illinois** Alvin B. Grant

Keith Main

DirectorPublic Health Research DivisionIndiana State Board of Health1330 West Michigan Street

Appendix D--BackgroundMaterial for Two OTA Surveys q 447

P.O. Box 1964Indianapolis IN 46206 1964

Jonathan Foley

Maryland Dept of Health& Mental

Thomas R. PiperDirector



Indianapolis, IN 46206-1964* State of Indiana** Keith Main

Mary EllisDirectorDept. of Public HealthLucas State Office BuildingDes Moines, IA 50319-0075* State of Iowa** Louise Lex, State Health Planner

Steve McDowellDirectorOffice of Rural HealthDept. of Health and EnvironmentLandon State Office Building, 10th Floor900 SW JacksonTopeka, KS 66612-1290* State of Kansas** Steve McDowell

Don CoffeyManagerHealth Resources Development BranchDivision for Health Policy & Resource

DevelopmentDept. of Health Services275 East Main StreetFrankfort, KY 40621* State of Kentucky** Don Coffey

Patrick O’ConnorDirector

Division of Policy& ProgramDevelopmentDept. of Health& Hospitals655 N. 5th Street, Suite 307Baton Rouge, LA 70802* State of Louisiana** Marcia L. Daigle, Director,Primary Care Coordinating Unit

Sophie GliddenOffice of Health Planning and

Development151 Capitol Street, Station 11Augusta, ME 04333* State of Maine** Sophie Glidden

Jeanette Washington

Health Planner

Maryland Health Resources Planning

CommissionP.O. BOX 2679

Baltimore, MD 21215-2299301/764-3323* MD Health Resource Planning

Commission** Jeanette Washington

Maryland Dept. of Health& MentalHygiene

201 W. Preston St., RM 314-B

Baltimore, MD 21201* Primary Care Cooperative Agreement

unit,Dept. of Health and Mental Hygiene** Jonathan Foley

Susan BernsteinDirector

Office of Local and Regional HealthMassachusetts Dept. of Public Health150 Tremont Street

Boston, MA 02111* Dept. of Public Health** Susan Bernstein & Hillel Liebert,

District Health Officer, Western

Massachusetts

Lou CrosbyPolicy Chief Division of Health Facility Planning&

Policy DevelopmentBureau of Health Facilities

Michigan Dept. of Public HealthP.O. Box 30195

Lansing, MI 48909* Division of Health Facility Planning &

&

Policy Development** Lou Crosby

Jim ParkerDirector

Community Health Services DivisionDept. of Health

717 Delaware St., S.E.Minneapolis, MN 55440

* Dept. of Health** Wayne R. Carlson, Director,

Community Development

Ella Tardy

Director

Office of Primary Care Liaison

Mississippi State Dept. of HealthP.O. Box 1700

Jackson, MS 39215-1700* Office of Primary Care Liaison

** Ella Tardy

Lorna WilsonDirector

Division of Local Health & Institutional

ServicesDept. of HealthP.O. Box 570

Jefferson City, MO 65102-0570

* Bureau of Primary Care,Division of Local Health& Institutional

Services** George A Thomas, Jr. program

Coordinator, Bureau of Primary Care

Director

Certificate of Need Program

Dept. of Health

P.O. Box 570Jefferson City, MO 65102* Certificate of Need Program** Thomas R. Piper

Charles AegenesChief Health Planning Bureau

Dept. of Health&Environmental SciencesCogswell Building, Capitol StationHelena, MT 59620

* Bureau of Health Planning** Charles Aegenes

David Palm

DirectorNebraska Office of Rural Health

Dept. of HealthP.O. Box 95007

Lincoln, NE 68509* State of Nebraska

** David Palm

Joseph Jarvis

State Health OfficerDivision of Health

Nevada Dept. of Human Resources

505 E King StreetCarson City, NV 89710* Division of Health** Ron L ange , Admin is t ra t ive

Health Services Officer

Caroline FordDirectorOffice of Rural Health

University of NevadaMackay Science, Rm. 201Reno, NV 89557-0046* Nevada Office of Rural Health

** Caroline Ford

William T. Wallace, Jr.Director

New Hampshire Division of Public HealthServices

6 Hazen DriveConcord, NH 03301* Division of Public Health Services

** John D. Bonds, Assistant Director for

Planning

Viktoria K. WoodResearch ScientistNew Jersey Dept. of Health

Local Health Development Services379 West State StreetTrenton, NJ 08625* State of New Jersey** Viktoria K. Wood


Harvey Licht

program ManagerSusan Ewing-Ramsay

Head

* Division of Hospitals

** William White



program Manager

Primary Care SectionDept. of Health& Environment

P.O. Box %8Santa Fe, NM 87501-0968

* Primary Care Section** Harvey Licht

Charles AlferoDirectorNew Mexico Health Resources, Inc.P.O. BOX 27650

Albuquerque, NM 87125* New Mexico Health Resources, Inc.

** Charles Alfero

Paul Fitzpatrick

New York State Dept. of HealthDivision of Planning, Policy, and Resource

Development

Empire State PlazaCorning Tower—Room 1656Albany, NY 12237* State of New York

** Assistant Chief Health Planner

James D. Bernstein

Chief North Carolina Office of Health Resources

Development

701 Barbour DriveRaleigh, NC 27603* Office of Health Resources Development** James D. Bernstein

Eugene S. Mayer

Program DirectorNorth Carolina AHEC program

CB #7165 Medical School Wing CUniversity of North Carolina/Chapel HillChapel Hill, NC 27599* North Carolina AHEC Program** Eugene S. Mayer

Robert M. Wentz

North Dakota State Dept. of Health&Consolidated Laboratories

Judicial Wing 2nd Fl600 E. Boulevard AveBismarck, ND 58505-0200

* State Dept. of Health** Robert M. Wentz

Jack GellerActing DirectorThe Center for Rural Health Services,

Policy & ResearchUniversity of North Dakota

501 Columbia RoadGrand Forks, ND 58201* Center for Rural Health Services,

Policy & Research** Lynett Krenelka, Grants Coordinator

Head

Primary Care SectionOhio Dept. of Health

246 N. High StreetColumbus, OH 43266-0118

* Primary Care Section** Susan Ewing Ramsay

Suzanne NicholsDirector

Oklahoma Health Planning CommissionDept. of Health1000 NE 10th St.Oklahoma City, OK 73152

* Oklahoma Health Planning Commission** Howard H. Vincent

Don K. Leavitt

Executive Director

Oklahoma Physician Manpower Training

CommissionP.O. Box 53551, Rm. 2111000 NE 10th St.Oklahoma City, OK 73152* Physician Manpower Training

Commission** Don K. Leavitt

Brent VanMeter

Deputy comissioner for Special HealthServices

Dept. of HealthP.O. Box 535511000 NE 10th St.

Oklahoma City, OK 73152

* State Dept. of Health** Brent VanMeter

Marsha R. Kilgore

Manager

State of Oregon Office of Rural Health1174 Chemeketa St. NESalem, OR 97301

* State of Oregon** Marsha R. Kilgore

Stephen MaleDirector

Bureau of Health Financing& ProgramDevelopment

Pennsylvania Dept. of HealthP.O. Box 90

Harrisburg, PA 17120* Bureau of Health Financing & Program

Development** Stephen Male

William WhiteDivision of Hospitals

Pennsylvania Dept. of HealthP.O. Box 90

Harrisburg, PA 17120

Sharon K. Cagen

Project DirectorCooperative Agreement for Primary Care

servicesRhode Island Dept. of Health75 Davis StreetProvidence, RI 02908* State of Rhode Island** Sharon K. Cagen

Thomas McGeeDirector

office of Primary careDept. of Health and EnvironmentalControl

2600 Bull StreetColumbia, SC 29201* office of Primary care** Tom McGee

Bernie OsbergRural Health ManagerSouth Dakota Office of Rural Health

Dept. of Health523 E CapitolPierre, SD 57501* Dept. of Health** Bernie Osberg

Scot Graff ManagerRural Health ProgramUniversity of South Dakota School of

Medicine2501 W. 22nd StreetSioux Falls, SD 57117-5346* University of South Dakota School of

Medicine** Scot Graff

Eloise HatmakerDivision of Health Access100 9th Avenue NorthNashville, TN 37219* State of Tennessee** Ray Davis, Director of Physician

Placement,& Annette Menees, Health Planner

Albert Randall

Associate Commissioner for Community& Rural Health

Dept. of Health1100 w 49th streetAustin, TX 78756* Dept. of Health** John Dombroski Director, Primary

Health Care Services program

Ellen WidessDirector of Rural HealthDept. of Agriculture

Appendix D--Background Material for Two OTA Surveys q 449

P.O. Box 12847Austin, TX 78711

Burlington, VT 05402

* State of Vermont** Ch i i

Division of Health

1800 Washington Street, East



* Dept. of Agriculture** Ellen Widess

Claudia SiegelDirector of Medical Programs

Texas Higher Education Coordinating BoardP.O. BOX 12788

Austin, TX 78711* Higher Education Coordinating Board

** Claudia Siegel

Robert W. Sherwood, Jr.

Director

Bureau of Local and Rural Health Systems

Utah Dept. of Health288 North 1460 West, P.O. Box 16660Salt Lake City, UT 84116-0660

* State of Utah** Robert W. Sherwood, Jr.

Christine FinleyHealth Planner

Vermont Dept. of Health60 Main Street-Box 70

** Christine Finley

Raymond O. PerryDirector

Office of Planning and RegulatoryServices

Division of Health Planning

Dept. of Health

1010 James Madison Building

109 Governor StreetRichmond, VA 23219

* State of Virginia** Raymond O. perry

Verne GibbsHealth Planning Administrator

Dept. of HealthMailstop OB-43FOlympia, WA 98504

* Dept. of Health

** Verne Gibbs

George W. Lilley, Jr.Acting Administrator

g ,

Building 3, RM 206

Charleston, WV 25305

* Dept. of Health** George W. Lilley, Jr.

Richard C. HeinzCoordinator

Primary care Programs

Division of Health

P.O. Box 1808

Madison, WI 53701-1808

* State of Wisconsin** Richard C. Heinz

R.L. Meuli

Director

State of Wyoming Health Dept.

Cheyenne, WY 82002* Wyoming Health Dept.

** Larry Goodmay




SURVEY OF STATE RURAL HEALTH ACTIVITIES

Spring 1988

Office of Technology AssessmentU.S. Congress

Washington, D.C. 20510-8025

Conducted by the Office of Technology Assessment

U.S. Congress



INSTRUCTIONS

1. READ OVER THE SURVEY CAREFULLY. If you have any questions, contact Leah

Wolfe or Marc Zimmerman at the Office of Technology Assessment, Health Program,

U.S. Congress, Washington, D.C. 20510-8025 (202/228-6590).

2. Please feel free to attach separate sheets whenever more room is needed for aresponse.

3. Please note that for each item in the ACTIVITIES section, we are interested only in

activities your organization is CURRENTLY involved in OR has been involved in

DURING THE PAST 3 YEARS.

4. Please make use of the “other” categories throughout the survey to capture any

activities/programs that we have not included in our checklists. Don’t forget to~these other activities in the spaces provided.

5. Please enclose any representative literature/publications you may have that will help

describe your activities/programs in greater detail, and feel free to reference this

literature at any point in the survey (e.g,, “See p. 26 of enclosed Annual Report for

description orour demonstration projects.”). A postage-paid envelope has been provided

for this purpose.

6. When you have finished, please enclose the completed questionnaire as well as any

related literature in the postage-paid envelope. Please return the survey by

Organization Name:

Address:

Phone:

Name/Title of director:

Name/Title of. otherkey contacc

Name/Title of persotscompleting survey

Year established

Type of organizatiosu

/

S t a t e G o v e r n m e n t - b a s e dU n i v e r s i t y - b a s e dP r i v a t e / n o n - p r o f i t

Other (describe)

(If rural health activkes are only part of your organization’s responsibilities,please make the following ~timates based on those activities alone.)

Number of people on staff: tTE (include professional, administrative, support)

Total annuat budget for rural programs (include federal, state, local, private, andfee-for-service income~

FY 87: s

N 88: S

N 8% S

Breakdowm % F e d e r a l f u n d i n g —% Local public funding% State funding — % Fee-for -service income

% Private funding (e.g., foundation grants)

Please list private funding sources

THANK YOU FOR YOUR TIME AND COOPERATION<

1PLEASE CONTINUE ON NEXT PAGE

q

1. GENERAL DESCRIPTION (CONTINUED) 2. ACTlVITIES.=. s.==. ====. .=. =.. ... ..=. ====. . . . . . . . . . . . . . . == . . . . . . . . . ... ===. = .=. =. == ..=..=.==



A) What are your organization’s rural health objectives? (Include your official mandate, if applicable.):

B) Was your organization established on the authority of State legislation or through anadministrative action?

C) Where within the organizational structure of the State government are you located? (Pleaseprovide an organizational chart if available.) If you are not a State agency, what is yourrelationship to the State government?

Please check those rural health activities below in which your organization has been DIRECTLYinvolved DURING THE PAST 3 YEARS. If your organization engages in/has engaged in anyactivities that are not listed here, please check “other” and describe these activities in the spaceprovided.

A: PROVIDER RECRUITMENT/PLACEMENT

NO, we have not done any provider recruitment or placement in the past 3 years.If NO, are there any other agencies/organizations in your State that do?Please give names:

YES, we engage/have engaged in the activities indicated below:

e of 00 lders PLACED OVER THE PAST 3 YEA RS:

(please putq 0” if you recruited but did not place anyone)

M. D.’s/D.O.’s Physician Assistants

R.N.’s Mental Health Professionals

— Nurse Practitioners

qOther (Please specify typea and give # PLACED OVER THE PAST 3 YEARS - e.g.,L. P. N.’s, Physicat Therapists, Pharmacists):

chec k all that a p p l y

— Loan forgiveness/repayment programs (Please describe):

— State scholarships in exchange for service in rural areas

— Other financial incen t ives

Placement service

— Other

.?PLEASE CONTINUE ON NEXT PAGE

3PLEASE CONTINUE ON NEXT PAGE

2. ACTIVITIES (CONTINUED)

B: FINANCIAL ASSISTANCE TO LOCAL ORGANIZATIONS

2. ACTIVITIES, C: TECHNICAL ASSISTANCE (CONTINUED)



B: FINANCIAL ASSISTANCE TO LOCAL ORGANIZATIONS

NO, we have not provided any financial assistance during the past 3 years.

if NO, are there any other agencies/organizations in your State that do?

Please give names:

YES, we have provided/provide the types of financial assistance checked below:

Loans (non-student) . . . .

Direct subsidy . . . . . . . .

Matching funds . . . . . . .

— Other (describe) . . . . . . .

C: TECHNICAL ASSISTANCE

(e.g., rural communities, local organizations,educational institutions)

NO, we have not provided any technical assistance during the past 3 years.

If NO, are there q nj other agencies/organizations in your State that do?

Please give tsaosex

— YES, we have provided/provide the types of technical assistance checked below.

( 1 ) — HMSA/MUA/MUP designations

(2)~. .

Statewide Mental health needs assessment

Date of last Statewide assessment

— Other needs aaaeaasoenta (describe)

— Community Board development

— Grant application aaaiatarsce

— - P-tig

— Resource identifiitiots

— WE

(3)~ts. . .1 vi

— Facility development/construction consultation— Grant application assistance

Management assistance

— O t h e r

D: RESEARCH

NO, we have not done any rural health research in the past 3 years.

11 NO, are there q ny other agencies/organizations in your State that do?Please give rsamex

YES, we have done/are doing research on the following topics (check all that apply):

PLEASE CONTINUE ON NEXT PAGE

4

PLEASE CONTINUE ON NEXT PA GE.

5

q

2. ACTIVITIES (CONTINUED)

E: RURAL HEALTH SYSTEMS COORDINATION AND IMPLEMENTATION

NO we have not engaged in any rural health systems coordination or implementation

2. A(’1 l\’lTIES (CONTIN(lI’D)

G: LEG AFFAIRS



NO, we have not engaged in any rural health systems coordination or implementationduring the past 3 years.

If NO, are there any other agencies/organizations in your State that do?

Please give names:

YES, we have engaged/engage in the activities checked below:

Developing alliances between hospitals~ types of participants (e.g.. urban/rural, large/small)

— Developing alliances between hospitals and other medical service facilities—(e.g.,m CHC’s, private physicians, mental health centers, county health depts.)~ types of participants:

Developing alliances ~ involving hospitals (e.g., AMONG CHC’s, private physicians,mental health centers, county health depts., community representatives)

Pka<e soecify types of participants:

G: LEG ISLATIY’E AFFAIRS

NO, we have not engaged in any Iegislat[ve affairs during the past 3 year-

If NO, are there any other agencies/organizations tn your State that do?

Please give names: ——.—

YES, we have engaged/engage in the activities checked below:

Development of task force/committee to address rural health care issues

Working with iegiskrture/legislative committees on rural health issues

— Othec

H: PUBLICATIONS

Please check below any rural health-related publications your organization has produced during the

past three years. Enclose representative samples if possible.

Annual report Information packets Research reports

Newsletter Evaluation reports — Newspaper articlesJ o u r n a l a r t i c l e s — Policy recommendations

Other

I: PRIORITIES

Pkar? check bdOW VP TO THREE activity areas which are currently your higheat priorities

A: PROVIDER RECRUITMENT/PLACEMENT — F: EDUCATION—

B: FINANCIAL ASSISTANCE TO LOCAL ORGANIZATIONS— — G: LEGISLATTVE AFFAIRS

— C: TECHNICAL ASSISTANCE — M< PUBLICATIONS

~ RESEARCH—

E: RURAL HEALTH SYSTEMS COORDINATION—AND IMPLEMENTATION

3. SPECIAL POPULATIONS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Please check below special populations to which any of your programs or activities

you indicated q bove are/have been specifically targeted

— Chifdren Racial/Ethnic groups

Elderly Please specify

— Low income

— Migsmtt workera — Uninsured

— Pregnant women — Ofhec

PLEASE CONTINUE ON NEXT PAGE 7

4. \lAJOR RURAL HEALTH CARE DELIVERY ISSUES IN YOUR STATE. . . . . . . . . = = = . . . . = . . . . . . . . . * = * . = * . . . . . . . . . . - - = . = - * - - - - - * - - - - - - - = = - - - = = - * - = = = = = = - =

GENERAL ISSUES: The following is a list of health care ~ELI v~ issues in rural areas. Please

5. QUESTIONS.=== ---- . as-==---- . ----= =--. - . . - .=. .- . .===.=.-==-=-=*--==*==-=======--=====-====

Please describe briefly (A) three CURRENT activities and programs in your State that have beeneffective in addressing rural health issues; and B) three activities or programs you would like to



rank each of the six issues by severity of the issue in your State, using ‘1- to indicate the biggestproblem area, ‘6” the smallest problem area. List and rank any other health care~ issuesin the space provided, expanding the ranking scale as necessary. r on YI

r?4tKc.

Health provider iasues (e.g., shortages, recruitment/retention)

Please specify:

Medical liability insurance costs/availability

Meeting the needs of special populations (e.g., elderly, migrant workers,high-risk pregnancies)

Payment issues (e.g., Medicare urban/rural differential, imsurance coverage)

Quality of care

services issues (e.g., hospital closures & restructuring, ayatema planning&development

Othec

see in your State ~ to address these issues.

A) Current Activities (3):

B) Future Activities (3}

SPECIFIC SERVICES Using the scale described below please indicate the amount of q ttention your

organization is CURRENTLY devoting to each of the following

RATING SCALE o 1 2 3 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5devoting NO devoting M06T

attention to this q ttention to this

(You may use each number more than once . . . )

Acute heatth care H o m e he a t t h c a m .

CM t d hesdth c a r e L o n g t e r m case

E m e r g e n c y m e d i c a l c a r e Mentat herdth c a r e

Heatth promotion/Disease obstetrics careprevention — othe~

— ~he~

THANK YOU VERY MUCH FOR YOUR TIME AND COOPERATION.

PLEASE CONTINUE ON NEAT PAGE

Ptease returrs aurvey by to: Lab Wotfe, Health Progmm, Offke of

Tachnotogy Aaseaament, U.S. Congress, Washington, DC 205t0-8025.

.

July 24, 1 9 8 9

CONGRESSIONAL OFFICE OF TECHNOLOGY ASSESSMENT’S

SURVEY OF STATES ONHEALTH PERSONNEL AND

c. Describe any problems tbat you bave bad in designating primary carepersonne l shortage areas the (i e



HEALTH PERSONNEL StlORTAGE AND

MEDICALLY UNDERSERVED AKEA DESIGNATIONSpersonne l shortage areas in the rural (i.e., nonmetropolitan) areaaof your State (e.g. ,designations in frontier areaa).

Name/Title of person

completing survey:

Neme/Titl.e of othercontact(a):

Organization Neme:

Addreas:Phone:

A.~ tio s

1. How satisfied are you with the criteria used to deaignate

G8re HealthMnvo er Sw hortaee Areas (lMSAs)?

Very satisfiedSatisfiedDissatisfied

V e r y dlsaatisfied

Den’t know

No opinion

Please describe why you areatisfied o rdissatisfied.

Federal Prima=

a. What changes would you suggest in the~ criteria thatwould inprove identification of primary care personnel shortage

areas?

b . W h e t a s p e c t s of the ~ criteria are good and should beretained?

2

3.

To what extent do you agree with the following statements:

a. A primary care NMSA’S priority grouping (i.e., group 1-4) is a good measure of the NMSA’S relative degree of primary care health

personnel ahortage.

Strongly agree

A g r e eDisagree

S t r o n g l y d i s a g r e eD o n ’ t k n o w N o o p i n i o n

Comment:

b. Allocation of Federal resources is correlated to N!4SA prioritygroups.

Strongly agree AgreeDisagree

S t r o n g l y d i s a g r e e

D o n ’ t k n o wNo o p i n i o n

Comment:

Please ~ describe trends in HNSA &signetion activity in your

State’s metropolitan and nonmetropolitan areas since 1980.

-1- -2-









D Genera Comments

Please provide any additional general comments that you have about thed i ti f i l h t di ll d d



designation of primary care personnel shortage areas or medically underserved

areas that have not been covered adequately by this questionnaire?

Comments:

Please return this questionnaire by ~umst4. 1989 in the self-addressedenvelope enclosed or send t o:

Rita Hughes

Office of Technology Assessment

Health Program

600 Pennsylvania Avenue, S.E.

Washington,.C. 20003

-11-

Appendix E

Rural Health Care Projects Funded by the Robert WoodJohnson Foundation and the W.K. Kellogg Foundation



Private foundations have played a significant role inpromoting innovative rural health care projects. Thesefoundations have intended to establish the basis forlasting, effective change through creative project plan-ning and design, research and experimentation, educationand training, and encouraging the coordination of com-munity resources. Two of the major foundations that haveprovided innovative support for rural health care pro-grams are The Robert Wood Johnson (RWJ) Foundationof Princeton, NJ and the W.K. Kellogg Foundation of Battle Creek, MI. Recent relevant projects supported bythe RWJ and Kellogg foundations are described brieflybelow.

The Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation, established in1972, in recent years has focused much of its efforts onbuilding and strengthening the infrastructure of the rural

health care system. The following describes those projectsthat are most specifically focused in this area.

q

q

q

Rural-oriented training activities supported by theFoundation in the early 1970s included: scholarshipsupport to encourage students from undeservedareas to go into medicine (a precursor of the NationalHealth Service Corps); and institutional support todevelop primary care training programs for physi-cians, physician assistants, child health practitioners,

nurse practitioners, family care assistants, and emer-gency care providers who represented those practi-tioners most needed in underserved areas.The Rural Practice Project was launched in 1975 todemonstrate how medical practices might be devel-oped in rural areas so as to meet both the health careneeds of the community, and the financial andprofessional needs of rural physicians. Foundationfunds were used to cover the operating deficits of the14 model rural practices for a period of 4 years. Some

sites were unable to achieve financial stability, andseveral had considerable staff turnover in physicians.The availability of a hospital to a practice was foundto be critical to financial and professional survivaland development.The Rural Infant Care Program, initiated in 1979,funded 10 medical schools to work with State healthdepartments in improving perinatal care in isolatedrural areas. The objective of this program was to

q

q

q

q

develop and enhance linkages between rural healthservices and tertiary medical centers and createregional networks of perinatal care. Although someof the medical services under this program were cutback or reorganized after Foundation funding ended,the regional relationships and services in manyStates that showed clear improvements in maternaland infant care remain substantially in place.The Rural Hospital Program of Extended Care

Services was launched in 1981 to encourage smallrural hospitals to develop swing-bed services.

2Five

State hospital associations were funded to developthe capability to provide technical assistance andeducation to interested rural hospitals. The Founda-tion subsequently funded 26 individual hospitals toimplement their particular swing-bed models andfunded an evaluation of the program, which foundpositive benefits both to the hospitals and their

communities. Rural Efforts To Assist Children at Home, a projectthat began in 1984, was funded in cooperation withthe Florida Department of Health and RehabilitativeServices and the University of Florida MedicalCenter. Under the program, 20 nurses from ruralcommunities received special training to assistuniversity-based pediatric specialists and local phy-sicians in providing routine management of chroni-cally ill children in the rural communities where they

lived. The nurses also worked with schools andfamilies to assist them in meeting the medical andrehabilitative needs of the children. Florida subse-quently extended the program statewide.The Hospital-Based Rural Health Care Program,

which began in 1987, funds consortia of ruralhospitals. Its goal is to allow rural hospitals toexplore strategies to strengthen their financial posi-tions, to explore alternatives to closing (e.g., conver-sions and diversification) and, where applicable, to

help them to close. The program emphasizes thedevelopment of regional affiliations to enable appro-priate referrals outside the community, and to enableclosure and conversion efforts to be examined withina regional context. Thirteen sites were funded andsome 185 hospitals participate in the program.In July, 1989, the Foundation awarded grants to 13community health care projects run by and forAmerican Indians and Alaska natives. Included are

1~orrnation for this appendix was provided by Nancy B arrand of The Robert Wood Johnson Foundation and Helen Grace of the W.K. Kellogg

F o u n d a t i o n .

2See ch . 6 for a discuss ion of hospital Swing be d ~W.

462–

Appendix E--Rural Health Care Projects q 463

projects designed to prevent alcohol and drug abuse,control diabetes, reduce domestic violence, andimprove maternal and infant health among tribalpopulations in eight States.

Target communities are characterized by high ratesof teenage pregnancy, trauma, substance abuse,sexually transmitted diseases, high levels of povertyand unemployment, few numbers of health care



The W.K. Kellogg Foundation

The W.K. Kellogg Foundation, established in 1930,concentrates most of its health-related philanthropy in theareas of community-based, problem-focused health serv-ices. Rural efforts focus on new collaborative approachesfor health services delivery, rural leadership development,and training of local government officials. Recent majorFoundation projects pertaining fully or in part to ruralhealth care are described below.

q

q

q

q

q

A 3-year project in northeastern Montgomery County,MD, which began in 1986, funded the creation of acommunity-wide network of volunteers to providesupport services not available to isolated elderly.Secondary goals were to transfer a share of theresponsibility for care of the elderly from thegovernment to the community, and to providemeaningful social roles for adolescents and elderly

through an intergenerational volunteer network Preliminary results suggest that the volunteer serv-ices have decreased the need for some hospital andnursing home services and provided relief to fami-lies.In 1989, the University of Illinois instituted a 3-yearproject whose goal is to train community-based,paraprofessional, primary care outreach workers tolink people in need of services with health careproviders. The project is oriented to both rural andinner-city residents.The Medical College of Georgia, in 1988, began a3-year project to reduce infant mortality and improvematernal and infant health in rural east centralGeorgia. Activities include establishing a case man-agement system for high-risk newborns using anelectronic database and discharge planning andinfant tracking program and using a nurse-managedmobile health unit to promote timely access to health

care for mothers, infants, and children in a medicallyunderserved rural area. I n 1988, the Children’s Defense Fund started a3-year project to reduce infant mortality and morbid-ity and adolescent pregnancy in rural MarlboroCounty, SC. The project used outreach workers toprovide health education and promote maternalcompliance for self-care of the mother and care of her infant.A 4-year project started by Mississippi’s Alcorn

State University, in 1987, is intended to improveaccess to health services for adolescents by provid-ing mobile health screening and services for youth innine rural and urban communities in Mississippi.

.

facilities and personnel, and poorly coordinatedsocial services.

In 1985, the University of North Dakota andLutheran Hospitals and Homes Society began a5-year project (the Affordable Rural Coalition forHealth (ARCH)). The project’s purpose is to reor-ganize health services to develop models of compre-hensive, integrated, cost-effective health care deliv-ery in several small communities in North Dakota,

Colorado, and Wyoming. Such restructuring maytake into account both horizontal (hospital to hospi-tal) and vertical (hospital to nursing home to homecare, etc.) relationships among major health careproviders. A second goal is the establishment of afuture-oriented, participatory process for communi-ties wishing to be involved in designing an optimalrural health care system.

Initiated in 1983, a regionalized demonstrationproject at the University of Washington School of

Medicine is designed to restructure the servicesprovided by selected rural hospitals in the States of Washington, Alaska, Montana, and Idaho. It isintended to demonstrate ways rural hospitals in thisregion can assess and modify their financial structureand the types, quantity, and quality of servicesprovided.

A joint project with the National Rural HealthAssociation and the Hospital Research and Educa-

tion Trust, which started in 1987, includes 13 ruralcommunity-oriented primary care demonstrationsfor the improvement of community-based healthservices. The project awarded grants to a variety of community health and human service organizations(e.g., group practices, community hospitals, publichealth departments, and social service agencies),who work with community leaders to define community-based health service needs and implement necessaryreorganization.

The 6-year Alliance for Rural Health ManagementImprovement project, which began in 1982, devel-oped a 7-part rural health care improvement programfor rural hospitals in 13 western States. The projectprovided training and job development for smallhospital executives and trustees; developed a volun-teer consulting corps of retired health care execu-tives; encouraged rural health care/small businessalliances and joint practice among rural hospitals;

improved quality assurance committees in ruralhealth care settings; and provided rural postgraduatefellowships to recent health administration gradu-ates.


q Two projects at the University of Alabama atBirmingham have focused on improving educationof allied health professionals. The first project,which began in 1976, established and disseminateda curriculum to train allied health generalists who

matched with health center preceptor sites. Oncompletion of the residencies, individual residentswill be matched with health centers where they willbe prepared to assume management positions.

. A 4-year project by the University of Missouri,



gcould perform a variety of basic tasks (e.g., assist inpatient examinations, administer medications, andkeep medical records). A second project, whichbegan in 1987, involves a series of clearinghouseactivities to document multiskilled models through-out the country, develop a consultancy program of experienced educators and practitioners, and dissem-inate information on multiskilled practice, includingan updated, state-of-the-art publication and direc-tory.

. In 1987, the National Association of CommunityHealth Centers (NACHC) began a 3-year project toproduce well-informed leaders for federally fundedcommunity and migrant health centers (urban andrural). The program selects qualified candidates to be

y p j y ystarted in 1987, is developing support services toassist the elderly to remain in home settings in theircommunity. The ‘Center On Rural Elderly” servesas a resource center for health and human serviceprofessionals interested in serving elderly whoreside in small towns and rural communities. Itdisseminates educational materials on topics such aspreventive health services, support for caregivers,and intergenerational relations between elderly per-sons and younger generations. In addition, Centerstaff are producing a planning guide to assist in thedevelopment and implementation of educationalprograms for local elderly groups and the develop-ment of programs to enhance the community in-volvement and leadership of recently retired persons.

Appendix F

Census and DHHS Regions



Census Regions

Northeast South Midwest West

New England South Atlantic West North Central Mountain

Connecticut Delaware Iowa ArizonaMaine Florida Kansas ColoradoMassachusetts Georgia Minnesota IdahoNew Hampshire Maryland Missouri MontanaRhode Island North Carolina Nebraska Nevada

Vermont South Carolina North Dakota New Mexico Mid Atlantic New Jersey

VirginiaWest Virginia

South Dakota Utah

East North Central Wyoming

New York -

East South Central Ohio Pacific

Pennsylvania Alabama Indiana AlaskaKentucky Illinois CaliforniaMississippi Michigan HawaiiTennessee Wisconsin Oregon

West South Central Washington

ArkansasLouisianaOklahomaTexas

U.S. Department of Health and Human Services (DHHS) Regions

Region I

ConnecticutMaineMassachusettsNew HampshireRhode IslandVermont

Region II

New JerseyNew York

Region III

DelawareMarylandPennsylvaniaVirginiawest Virginia

Region IV Region VI Region IX

Alabama Arkansas ArizonaFlorida Louisiana CaliforniaGeorgia New Mexico HawaiiKentucky Oklahoma NevadaMississippi Texas GuamNorth CarolinaSouth Carolina Region VII Region X

Tennessee Iowa Alaska

Region VKansas IdahoMissouri Oregon

Illinois Nebraska WashingtonIndianaMichigan

Region VIII

Minnesota ColoradoOhio MontanaWisconsin North Dakota

South DakotaUtahWyoming


Figure F-1—U.S. Showing Census Divisions and Regions

WEST

P ifi M t i

MIDWEST

W t E t

NORTHEAST

Middl N



Pacific Mountain West EastNorth Central North Central

1

ND I‘~ MN

- - - - - - - - - 4SD ‘1

I1 - - . I .. ; . . . . . I I I \ / [ WI‘(I

I

C A N “ — ~ - - ’ j - - - - j

!

I

..- . i , t I . . , ‘, OH ?

Middle NewAtlantic England

VT

‘ u r ‘- --e~----

a

SOURCE: U.S. Bureau of the Census.

EastWest SouthSouth Central Central

SOUTH

South Atlantic

D.C.

Appendix G

Field Workshops

During the course of the Rural Health study the Office improve public image and perceived quality



During the course of the Rural Health study, the Officeof Technology Assessment (OTA) held three field work-shops. At these workshops, invited participants presentedproblems and suggested strategies and discussed themwith attending OTA staff, advisory panel members, andobservers.

The first workshop, held on January 11, 1989 inScottsdale, Arizona, addressed issues and strategic op-tions for small, isolated hospitals; larger rural hospitals

and those operating in more competitive environments;and rural hospitals in multihospital systems or otheraffiliations. On February 28,1989, OTA held a workshopon health personnel issues, with a special emphasis on theneeds of ‘‘frontier” areas, in Bismarck, North Dakota.Topics included training, recruitment, retention, andpractice issues for rural health professionals. The thirdworkshop, held on June 15, 1989 in Meridian, Missis-sippi, addressed issues related to providing primary careto rural populations, especially those in persistent pov-

erty. Topics included payment and financing, access tocare, and practice capacity and organization.

Summary of presentations from invited workshopparticipants follow.

Scottsdale, Arizona

Small, Isolated Hospitals

James Armstrong, President, Sierra Vista Hospital,Truth or Consequences, NM—Represents a 34-bedAdventist hospital in a community of 7,000. The nexthospital is 75 miles away. The community has a largeinflux of tourists in the summer and semipermanentretirees in the winter. Seventy to eighty percent of thehospital’s patients receive Medicare.

Problems—q lost $500,000 last year, low Medicare reimburse-

ment,

. 30 to 40 percent of population is going elsewhere forcare,

q expanded need for elderly and emergency medicalservices (EMS) due to tourism and retirees,

. physician and nurse recruitment and retention,

. community slow to change.

Strategies—qcut expenses or forego staff expansion,

improve public image and perceived quality,air and ground transport in EMS network trained six licensed practical nurses to registerednurses,educate physicians to maximize reimbursement.

Elton Summers, Administrator, Gila County General Hospital, Globe, AZ—Represents a 35-bed public(county)hospital in a town of about 7,000 people. There is acompeting nonprofit hospital about 6 miles away.

Problems—q about $1 million in uncompensated care (out of $8

million total),. seen as social service agency by community and

county government,q low occupancy rates.

Strategies— . improve business management,q long-term strategy to try to merge with competing

hospital. 2

Harold Brown, Chief Executive Officer (CEO), Prai- rie du Chien Memorial Hospital, Prairie du Chien,WI)--Represents a nonprofit hospital with 49 acute beds,swing beds, 4 skilled beds, 2 respite beds, home health,and hospice. The next hospital is 30 miles away and thenext large hospital is 65 miles. The hospital was in theblack last year. It has 62 percent occupancy in its acutecare beds, which generated 57 percent of its revenue. Of

the remaining revenue, 24 percent is from outpatientservices.

Problems— . access to capital for modernization and expansion,qproposed prospective payment for ambulatory serv-

ices would pay only 70 percent of x-ray costs and 67percent of lab,

q regulations for many services are not sensitive torural situation.

Strategies-q

q

q

q

maximized Medicare payments through high baseyear costs,diversifying from inpatient to outpatient services,developing local funding via foundation and fund-raising,report cards for doctors on handling cases andpatients.

1~ ~ ~O-P ~a -~ ~= ~~~Ct ~ the N~~~ R~ H~~ Assw~tiOII, me m@@ h M~~ Mississippi was _ bythe National Rural Health Association with assistance from the National Association of Commonity HeaIth Centers, the Mississippi Primary CareAmeiatioq and the AlabamaRimary Health Care Asaoeiation.

% 1989, Gila County General Hospital annound plans to merge with the nearby nonprofit hospital, 49-bed Miami Inspiration Hospital.

47-


Bill M. Welch, Administrator, Elko General Hospital, Elko, NV—Represents a 50-bed public hospital with nocounty subsidy. The service area is growing rapidly andnow has 27,000 people, but the county’s populationdensity is still 1.6 per square mile. It is about 150 milesto the next hospital

Douglas Fonnesbeck, Administrator, Logan Regional Hospital, Logan, UT—Represents a 150-bed hospitalthat is a member of Intermountain Health, Inc. Thecommunity is growing and has a diversified economicbase.



to the next hospital.

Problems-

qphysician shortage acute,. increasing accounts receivable,q competition with urban hospitals outreaching into

area,q facility designed for inpatient services, but about 50

percent are outpatient services.

Strategies— . intense community-based physician recruitment,q using contract collection firm,. local media campaign to retain market share,. developing statewide rural hospital consortium,q use consultants to help identify problems and

planning with board.

Larger Rural Hospitals and Those in More

Competitive Environments Patrick Linton, CEO, Yavapai Regional Medical

Center, Prescott, AZ—Represents a 129-bed hospital ina town of 25,000. Over 30 percent of the population isover 65 years old. About 54 percent of revenue is fromMedicare and 9 percent is from Medicaid.

Problems--q low rural payments from Medicare and resulting low

morale,

. lack of access to capital,

. aging physical facility,qhigh proportion of elderly.

Strategies— . Geriatric Resource Center (foundation funded) to

case manage patients and families,. joined State federation of six hospitals to raise

capital.

Steve Ward, Director, Shared Services & Outreach,St. Mary’s Hospital, Grand Junction, CO—Representsa 294-bed rural referral center (RRC) in the mountains.

Problems--q indigent care costs rising,q competition from urban referral centers.

Strategies— . favorable payments under RRC designation,q Considering transportation for physician care and

other services,q strong outreach and marketing program to solidify

market.

Problems—qaccess to capital,. deciding ‘‘what you are and what you are not,”qMedicare reimbursement.

Strategies— . business-based strategic planning,. strong guest relations program,. acute-care case management program.

Virginia Goodrich, Executive Vice President, New Mexico Hospital Association-Represents Rehoboth-McKinley Christian Health Care, Gallup, NM, created bythe merger of a 41- and a 81-bed hospital. The currenthospital has 74 acute care beds. The area has a multicultu-ral population and a depressed economy.

Problems—q competing, inefficient hospitals in the same town,. large indigent population,

. Medicare reimbursement inadequate,q training costs high due to multilingual requirements,q red tape in working with Indian Health Service

hospital,. high accounts receivable,q community image makes recruiting difficult.

Strategies—merged facilities with agreement to protect jobs for1 year,

cut 100 jobs after l-year hiatus,easy merger of medical staffs helped bring harmony,methodical attention to and elimination of accountsreceivable,serious planning effort for merged facility.

Rural Hospitals in Systems or Other Affiliations

James R. Beeler, Director of Planning & Marketing/ Regional Operations, Samaritan Health Service, Phoe-

nix, AZ-Represents system of 18 facilities (mostlyleased or managed), of which 4 are hospitals ranging from25 to 84 beds in size.

Problems— . heavy subsidy of one 22-bed rural hospital,. manpower recruitment and stabilization,. physician issues,q access to capital.

Strategies—

. converted troubled hospital to other uses,. internal recruiting/locum tenens,q joint venture With physicians in managed care plan,

Appendix G--Field Workshops q 469

q prescreening outreaching specialists,q air transport of specialists to rural areas,

q pooled bond fund provides access to capital,q local fundraising.

Keith Lundberg Executive Director Health Services

Strategies— . board retreats,qpeer support visits to provide internal review and

assistance,

q joint purchasingmanagement information s stem and cost report



Keith Lundberg, Executive Director, Health ServicesConsortium, Seattle, WA—Represents a voluntaryshared services consortium established in 1973 under theauspices of a large tertiary center. There are 15 ruralcommunity hospitals in the consortium.

Problems--q low utilization,. recruitment and retention of physicians.

Strategies—q coordinated case management,q focused referral relationships,. developing physician leadership,. tangible incentives for patient care relationships.

Carole Guinane, R.N., Asst. Vice President for Medical Staff Services, Parkview Episcopal Medical

Center, Pueblo, CO—Parkview joined with Rose Medi-cal Center in Denver to form the Rocky Mountain Health

Alliance to provide a link for rural institutions andphysicians to the resources at tertiary care facilities andgarner referrals for the larger hospitals.

Problems—qurban hospitals seen as “black hole” for referrals,. rurals losing market share due to poor image,q t ra in ing and continuing education needs,q few resources for new equipment and services.

Strategies--q specialty physicians contract to return patients to

rural physicians,q training programs for rural doctors, nurses and

administrators,q inventory reduction program; equipment purchase

and placement,qgrantswriting assistance,qmarketing and strategic planning assistance.

Gordon Russell, Administrator, Hi-Plains Hospital, Hale Center, TX—Represents the West Texas Independ-ent Affiliated Hospitals, a group of about 30 ruralhospitals that are about 40 miles apart covering an area thesize of New York. The hospitals average 49 beds in size,and most are public.

Problems—not enough money, competitors have too muchmoney,

low Medicare reimbursement,isolation resulting in unsophisticated systems andresistance of change,peer Review Organization problems.

20-810 0 - 90 - 16 QL3

joint purchasing,qmanagement information system and cost report

sharing.

Cathy Comito, Network Coordinator, Mercy Hospital Consortium, Des Moines, IA—Represents a consortiumconsisting of 10 rural hospitals within a 100-mile radiusof Mercy Hospital in Des Moines. Eight of the hospitalsare county; two are nonprofit. Five are managed by Mercyand five are affiliated.

Problems—q isolation,

q inefficiency.

Strategies-q

q

q

q

q

local autonomy is key,no management fees are charged,training programs for all levels of personnel,hospitals purchase services from consortium,consortium-wide conferences for board and adminis-

trative staffs.

Bismarck, North Dakota

Physician Issues

Nelson Tilden, Ph.D., President, Medical SearchConsultants, Inc., Overland Park, KS-Operates a smallconsulting firm that recruits physician, particularly forrural areas.

Problems— . lifestyle expectations of young physicians often

antithetical to rural practice,q increasing numbers of women physicians whose

spouses often have trouble finding positions in ruralcommunities and who tend to have different practicestyles and needs (e.g., more time with family, childcare, etc.).

Strategies—

q

q

q

q

revitalize the National Health Service Corps (NHSC),implement the Resource Based Relative Value Scale(RB/RVS) quickly,establish a ‘‘Peace Corps’ ‘-type program that re-quires all graduating physicians to serve in amedically underserved area,encourage programs to provide “call” coverage,professional interaction, and emotional support forphysicians.

Frank Newman, Ph.D., Director, Montana Area Health Education Center (AHEC), Bozeman, MT—Represents interests and concerns of Montana’s 45frontier counties. In 1987,52 percent of the counties in the


State were designated as Health Manpower ShortageAreas. There are 60 hospitals and 45 are rural hospitals of 60 beds or less.

Problems—q maldistribution of physicians is a problem despite

Carol Miller, President, Mountain Management, Ojo

Sarco, NM—Represents concerns of “frontier” areas.

Problems— . cutbacks in Federal funding,

q physician maldistribution,



q

q

q

q

maldistribution of physicians is a problem despitethe fact that the State has a physician-to-populationratio of 1:650. Only 33 percent (417 doctors) areserving the rural 70 percent of the population,all of the State’s small rural hospitals are losingmoney,Indian reservations have a very hard time recruitingdoctors and low retention rates,a 90 percent occupancy rate exists in the State’s

nursing homes, but only a 25 percent occupancy inthe rural hospitals,the two federally funded community health centers(CHCs) are both in urban areas.

Strategies—q

q

q

q

q

creation of State offices of rural health and State ruralhealth associations,Indian health programs have retained a fulltimerecruiter which placed 16 doctors last year,

CHCs should be established in rural areas,the WAMI (Washington, Alaska, Montana, Idaho)program of rural rotations,the AHEC maintains and publishes practice vacancylists each month, and helps recruit doctors to theState.

Gerald Sailer, M.D., United Clinics, Hettinger, ND—Represents a 17-doctor practice in a medically remotearea. The practice created a health maintenance organiza-tion (HMO) that ceased operations in January 1989.

Problems—q

q

q

q

q

peer support is unavailable unless through grouppractice or other arrangements,time for family must be planned into physicianretention plans,doctors often are not educated for the demands of rural practice,payments for rural doctors and hospitals is very low,procedure-oriented physicians are paid much more

than cognitive physicians.

Strategies—q

q

q

q

q

adopt RB/RVS without geographic differences,equalize urban and rural payments for similarservices for both hospitals and physicians,pay for nurse-anesthetist services at cost in hospitalseligible for Sole Community Hospital (SCH) desig-nation,develop payment rates for rural HMOs that are not

based on usual and customary rates, which perpetu-ates payment inequities,refine the definition of and payments to assure thatnecessary hospitals survive.

q physician maldistribution,. reductions in funding have crippled rural and frontier

communities’ ability to recruit health professionals,qmedical indigency is a primary barrier to access.

Strategies— . restore and improve the NHSC,q expand Medicaid to assure the same coverage in all

States,

q provide tax credits and incentives for rural practice,. provide locum tenens coverage for doctors’ vaca-

tions and continuing medical education (CME),. make Federal CHC and NHSC programs more

available for small sites in rural and frontier areas.

Nursing Issues

Lois Merrill, Dean, College of Nursing University of

North Dakota, Grand Forks, ND—Represents concerns

of nurses and their employees. Problems—

rural nurses and facilities can’t afford additionaltraining required by modern practice,reimbursement for rural hospitals makes them una-ble to compete with urban hospitals for nurses,urban hospitals are raiding rural areas for nurses,direct reimbursement for advanced degree nurses isunavailable.

Strategies— . support outreach education,. financial aid should recognize the needs of adults,q reimburse rural hospitals equitably, recognizingg the

increased demand and pay scales for nurses,q provide indirect payments for nurse training as is

available for physician training,. direct reimbursement for nurse practitioners, nurse

midwives and certified registered nurse anesthetists.

Sue Ebertowski, R.N., Director of Nursing, Mercy Hospital, Williston, ND—Represents a 125-bed ruralhospital, 200 miles from the nearest tertiary hospital. It ispaid rural rates and has an occupancy rate of 35 to 40percent. The nursing staff has a 21 percent turnover rateand currently has no vacancies.

Problems—obsolete job and work structures,insufficient job feedback,

lack of participation in decision-making,first line manager deficiencies,ineffective nurse-to-nurse relationships,ineffective nurse-to-physician relationships,

Appendix G--Field Workshops q 471

nonproductive nurse-to-ancillary department rela-tionships,high stress among nurses,lack of innovative environment,

deficient internal and external image of nursing,untargeted and ineffective recruitment marketing,

A Potpourris of Related Issues

Dwayne Ollerich, Ph.D., Academic & Research Af- fairs, University of North Dakota School of Medicine,Grand Forks, ND—Represents general economic con-

cerns of rural North Dakota, where agricultural economyh b il l h d d d l i



g gg g,inadequate wage systems,nursing technology lag,underdeveloped strategic plans for the nursing or-ganization.

Karen Pederson-Halle, R.N., Luke Regional District Health Unit, Devils Lake, ND—Represents a healthdepartment unit that serves five counties, an area of 5,835square miles. There are 6.6 full-time equivalent nurses,and the Unit should have four more nurses to meetstandard staffing ratios. The Unit provides communityhealth nursing, WIC, family planning, health screeningand environmental health services to a population of over38,000.

Problems—q

q

q

q

q

q

salaries are considerably lower than in local hospitalsand even lower compared to city hospitals in theState,

the area is not considered attractive to many nurseswith the largest town having a population of only750,little chance for advancement,declining funding for public health programs,difficult to identify results from preventive care,need to be better versed in politics and public speaking.

Strategies—

. increase funding for public health programs,. train nurses for community and rural practice,. develop career ladders within region.

Hurdis Griffith, R. N., Ph.D., University of Texas,

Austin, TX—Represents concerns of rural nurse practi-tioners (NPs).

Problems—low pay for NPs (rural NPs average $13.36/hr),

lack of recognition of capabilities of NPs to functionindependently,State laws and their interpretation are sometimes realbarriers to implementation of Rural Health ClinicsAct (RHCs),many third-party payers do not reimburse for NPs’services.

Strategies— . simplify RHC reporting, which is currently not

feasible in small sites,. establish NP traineeships to help train local nurses to

become NPs,. .

q provide direct reimbursement for NPs' services.

g yhas been poor, retail sales have dropped, and populationand jobs have declined.

Problems-q underemployment of rural residents,. lack of outreach training available that will allow

rural, residents to train while employed or in theirown communities.

Strategies— . need assistance grants for transition from farming toother employment,

. programs to develop leadership within local re-sources,

q need support for students for travel, tuition and childcare,

q should use new communications technology forlocal training.

Tom Robertson, Director, Southeast Montana Rural Health Initiative, Glendive, MT—Represents a countyhealth department that serves a geographically largefive-county area with a population of 85,000. He is alsopart-time director of the SE Montana Rural HealthInitiative, a primary care program that no longer hasfunding from the CHC program. Most of the people in thearea consider themselves lucky to live within 50 miles of a physician or a physician’s assistant (PA).

Problems— . recruitment and retention of all health personnel,

especially emergency medical technicians (EMTs),q very long drives for training and services with no one

picking up the costs of that travel,

. EMT testing is often provided 200 to 300 milesaway,

. low pay rates for health professionals is a disincen-tive for retention.

Strategies—q

q

q

q

training throughout rural and frontier areas fundedby the Public Health Service,payment for more services not covered by currenthome health programs for frontier areas,allow more flexibility in productivity and otherstandard in the CHC Program,allow more multiple-county CHC projects.

Pam Locken, Administrator, Isabel Community Clinic,

Isabel, SD—Represents a CHC staffed by a solo PAwhose backup physician supervisor is 104 miles away byair transport. The clinic is between two Indian reserva-


tions. It is 60 miles to the nearest hospital. The averageage in the three-county service area is 19 years old.

Problems—

q poor counties with low tax base,

. no backup for PA when he is on vacation or CMEtravel

q

q

q

per capita for health care than urban areas,rural people are disproportionately poor and oftenineligible for Medicaid,rural CHCs serve 50 percent of all CHC users, but

receive only 41 percent of Federal CHC funding,rural CHCs are required to provide the same scope of



travel,. bad weather limits ability to transport,q nearest pharmacy is 55 miles away,. Indian Health Service will not acknowledge PA’s

prescription.

Strategies—q certification as RHC allows payments to cover

relatively high per unit cost,

c all staff are cross-trained to do others’ jobs,q use starter doses for prescriptions until mail truck can

deliver medications.

Denise Denton, Rural Health Field Coordinator,

Utah Department of Health, Salt Luke City, UT—Utahis 83 percent frontier and about 90 percent rural. TheState’s rural health effort was begun with a NHSCcontract in 1982. At that time the State had 12 to 15 newCorps assignees per year, and a total of 25 to 33 assignees

in the State. In 1986 the number of new assignees wasfour, and in 1988 there were no new assignees.

Problems— . family physician supply is too small to meet the need

in both urban and rural areas,q need better training for communities on how to

recruit and retain,. professional liability is driving doctors out of rural

practice,

. grantwriting abilities of many rural communities isweak,

. inequitable reimbursement for physicians provides adisincentive for rural practice.

Strategies—q

q

q

q

provide locum tenens coverage for doctors, PAs andNPs,tie midlevel providers in with teaching hospitals,provide financial incentives for medical schools todo rural programs,

develop a more relevant rural curriculum for traininghealth professionals.

Meridian, Mississippi

Payment and Financing

Alan Strange, Ph.D., Consultant, National Associa- tion of Community Health Centers, Washington, DC—Represents the concerns of the Nation’s federally funded

536 CHCs, of which 329 (63 percent) are rural. Problems— . rural areas receive 42 percent fewer Federal dollars

rural CHCs are required to provide the same scope of services, but lack the economies of scale of largerpractices.

Strategies—compulsory service for providers completing train-ing,improve reimbursement under the Rural HealthClinics and the federally Funded Health Centers

Programs,expand the Hospital Transition Grant Program toinclude CHCs,increase funding for the NHSC,allocate funds targeted for special populations (AIDS,homeless, infant mortality, etc.) on the same basis asbasic appropriations.

Penella M. Washington, Health Resources Develop- ment Section, North Carolina Department of Human

Resources, Raleigh, NC—Represents the State of NorthCarolina’s concerns regarding helping providers becomecertified as RHCs.

Problems—q

q

q

q

q

q

timeframe for certification (from date of applicationto date eligible for claim reimbursement) is too long(6-9 months),centers awaiting certification must discontinue Medicare/ Medicaid billing during the approval process, caus-

ing cash-flow problems,midlevel providers are required to be onsite at least60 percent of the time the clinic operates, whichlimits staffing flexibility,annual recertification surveys are conducted withoutprior notification of the clinic, hence appropriatepersonnel may be absent. Current methodology forcalculating productivity screens contains disincen-tives for exceeding productivity standards,documentation required for reimbursement for baddebt is often difficult for small clinics to produce,HCFA regions and intermediaries interpret programregulations inconsistently.

Strategies—q

q

q

q

make federally funded CHCs automatically eligiblefor RHC certification, and streamline process to nolonger than 3 months,lower midlevel provider requirement to 50 percent of time the clinic is open based on a 12-month fiscalyear,advise clinics of recertification surveys in advance,develop a “team approach” to computing productivity,

Appendix G--Field Workshops .473

qsimplify the bad debt recovery process by paying 90percent of estimated bad debt.

William A. Curry, M.D., F.A.C.P., Carrollton, AL-Represents a private medical group practice that consists

of four internists. The local hospital has a medical staff of 10 Local citizens recently passed by a 3 to 1 margin a 3

Access to Care

Rims Barber, Director, Mississippi Human Services Agenda, Jackson, MS—Represents the concerns of therural poor.

Problems—



10. Local citizens recently passed by a 3 to 1 margin a 3percent sales tax to support the local hospital.

Problems—c problems of rural hospitals, doctors, etc. are inter-

connected,

. structural changes imposed from above won’t work;we need to look for “free market” approaches,

q

inequitable reimbursement is the major problem forboth rural hospitals and doctors,

. alternative model that would turn rural hospitals intosimple triage and transport facilities will not beefficient or effective.

Strategies— . reform the payment system for Medicare and Medi-

caid to provide equitable payments for rural doctorsand hospitals,

. adopt the RB/RVS with adjustments for cost of practice, not cost of living,

. reform Medicaid.

Clinton Smith, M.D., Director, Division of Medicaid,

Office of the Governor, Jackson, MS—Represents theMississippi Medicaid Program.

Problems— . shortages of doctors, nurses and other health profes-

sionals to practice in rural areas,q rising rates of uncompensated care in hospitals,

. hospitals and doctors dropping obstetrical service,

q transportation, even though it is reimbursable underMedicaid,

q categorical eligibility for Medicaid unfairly restrictscoverage.

Strategies-

provide focused incentives for people to enter healthprofessions and practice in rural areas,

provide fair reimbursement under Medicaid andMedicare; equal for both urban and rural providers,

allow States to selectively increase payments forobstetrical care,

develop public transportation in rural areas,

dissociate Medicaid eligibility from Aid to FamiliesWith Dependent Children, and use more universal

standard such as Federal poverty level,expand Medicaid coverage for persons between 21and 65 years.

. slow Medicaid application processing,. transportation for the rural poor is difficult to find

and expensive,. home environments often lack basic amenities,. high rates of teenage pregnancy.

Strategies— . develop a program of ‘‘community facilitators’

within CHCs or other entities,. simplify eligibility and expand coverage underMedicaid,

. mandatory Medicaid participation for doctors toassure that the poor have services available.

Mickey Goodson, Executive Director, Georgia Asso- ciation for Primary Health Care, Atlanta, GA— Repre-sents primary care providers in Georgia, which has 159counties (120 with hospitals, 150 with physicians).

Nineteen percent of the rural population is poor. Problems— . economic status is still a major obstacle to access,q indigent care burden falls heavily on rural providers,qmaldistribution of doctors and other health profes-

sionals.

Strategies— . more emphasis on comprehensive primary care

models of delivery,

. provide universal access to basic services.

Susan Jones, M.D., West Alabama Health Services, Eutaw, AL-Represents a primary care center thatsponsors a three-county program to reduce teen pregnan-cies and improve pregnancy outcomes.

Problems—q shortage of physicians for rural practice,qhigh infant mortality rates in rural areas that are twice

as high for black infants.Strategies—q funding for programs targeted for specific problems

and population segments,. develop comprehensive systems which include trans-

portation, tracking systems and home visiting,. revitalize the NHSC.

Pamela Hammock, State Health Office, Tallahassee,FL-Represents the State of Florida, which passed a law

in 1984 to create the Public Medical Assistance TrustFund, funded by a combination of taxes on hospitalrevenues and general revenue from the State. The Fund


has supported primary care projects in all 67 counties andpermitted the State to expand Medicaid coverage.

Problems— . rising and maldistributed indigent care costs,

. poor access to primary health care,q restricted Medicaid eligibility.

Strategies--. more NHSC physicians for rural practice,qregionalized training for small clinics to help with

efficiency and quality,q establish linkages with community agencies and

programs,qmore CHC funding to cover increasing indigent care



Strategies— . State funds similar to the Florida model can work to

provide additional access for the poor and providefunds for other developmental purposes.

Practice Capacity and Organization

Steven Shattls, Executive Director, Valley Health

Systems, Huntington, WV-Represents a primary carehealth system with a wide array of services, including aperinatal program (which serves 70 percent of the eligiblewomen in a 10,000 square mile area) and to the homeless.The system is located in West Virginia, which isdependent on coal mining in a deep economic depression,and nearly bankrupt.

Problems—q

q

q

q

q

high reliance on the NHSC for physician manpowerand low retention,

categorical funding restricts ability to use funds tomeet the needs of the community,limited funding and reimbursement,transportation,coordinated care important but difficult in ruralareas.

Strategies—q joint approaches to retention with hospitals and

public and private providers,qmore flexibility and creativity in using categorical

funding,qmore aggressively seek categorical funding,qmore money for case management programs.

Al Fox, Executive Director, Health Development

Corp., Tuscaloosa, AL-Represents a system that pro-vides primary health care for six counties. Its initialmission was to recruit and place health professionals inpractices that would become stable private practices. Over

an n-year period, it placed 16 physicians and 3 dentistsin independent practices. In 1987, it changed its programto conform with the CHC Program to operate comprehen-sive health centers rather than setting up private practices.

Problems—q hospital closures hurt recruitment and retention

efforts,q need for stronger working relationships with public

health,q need for standardization in small clinics,

. low per capita incomes and high indigent care load.

qmore CHC funding to cover increasing indigent careload.

Bernard Simmons, Executive Director, Southwest Health Agency for Rural People, Tylertown, MS—Represents a primary health care center in a rural area withno shortage of health manpower but with a high rate of poverty.

Problems— . financial barriers prevent access to care for manyresidents,

q teen pregnancy rate is 25.4 percent,q initial perception of program as a “Federal clinic”

with low participation from White population.

Strategies—q

q

q

q

expand Medicaid to include more of population,interact with local private providers to give “team

approach” to health care,funding for midlevel providers to help clinicsbecome certified as RHCs,funding for social workers or others to act as casemanagers.

Shirley Parker, Executive Director, Laurel Forklear Fork Health Centers, Clairfield, TN—Represents anetwork of four small clinics located in Eastern Tennesseeand Kentucky in areas where organized health care wasfirst provided by “camp doctors” hired by the miningcompanies. Fifty-five percent of the people in the servicehave incomes below the poverty level.

Problems— . high proportion of indigent care,q recruitment and retention,q need for automation of billing and bookkeeping

functions,qhigh cost for medical liability insurance,. increasing facility repair and maintenance costs.

Strategies—q

q

q

q

q

q

q

increases in grant funds should be tagged to increas-ing patient load and indigent care load,excess program income should be retained by centersto use or to save as they see fit,tort reform needed on malpractice,provide tax credits or deductions for rural doctors,better reimbursement for mid-level providers,more rural-based training programs for physicians,

renovation money should be made available.

Appendix H

Summary of OTA Special Report onRural Emergency Medical Services

The average U S resident will need ambulance service tance in improving the supply and level of skills of rural



The average U.S. resident will need ambulance serviceat least twice in his or her lifetime; and for some of thesepatients, delays in receiving emergency care will contrib-ute to death or permanent injury. The one-quarter of Americans who live in rural areas, which occupy four-fifths of the country’s land area, face special problems inreceiving emergency care. It is difficult to deliveremergency medical services (EMS) to widely dispersed

populations quickly, and in small rural communities theremay be less than one emergency call a day. This relativelylow volume of calls may mean that a rural ambulanceservice cannot support itself financially and that ruralEMS providers have difficulty maintaining their special-ized skills. The time it takes to reach emergency patientsmay always be longer in some rural areas than urban areasbecause of distances between services and rural residents.

While problems relating to population dispersion arenot easily amenable to intervention, many of the problems

rural EMS providers are having in delivering EMS carecan be alleviated with additional resources and system-wide planning. Among these problems are:

. EMS personnel shortages;

. inadequate advanced training opportunities for avail-able EMS providers;

. a lack of medical supervision of local EMS operations;q antiquated equipment (e.g., communications equip-

ment);

. poor public access to EMS; and

. an absence of regionalized systems of specializedEMS care, such as trauma systems.

The Federal role in supporting State EMS programs haswaned in recent years, but evidence of serious impedi-ments to quality EMS care in rural areas argues for anincreased Federal role. Limited Federal resources mightsuccessfully be used to:

q

q

q

q

q

promote training of EMS providers;

facilitate the development of national consensusguidelines or standards for prehospital EMS provid-ers and EMS facilities;provide technical assistance to States;support EMS-related research and demonstrationprojects; andprovide incentives for States to implement EMSplanning efforts.

Specific Federal options to be considered include:

. Federal Initiatives in EMS Training-Option 1: Congress could fund the Department of

Health and Human Services (DHHS) to provide assis-

tance in improving the supply and level of skills of ruralprehospital and hospital-based EMS providers. IncreasedFederal assistance could include support of EMS trainingand continuing education programs, and State recruitmentand placement programs.

-Option 2: Congress could require the Department of Transportation (DOT) to reevaluate the standard curriculafor EMS providers.

q Federal Guidelines or Standards

-Option 3: Federal legislation could facilitate thedevelopment of national consensus guidelines or stand-ards for prehospital EMS providers.

-Option 4: Federal legislation could facilitate thedevelopment of national consensus guidelines or stand-ards for specialized EMS facilities such as trauma centers.Such guidelines or standards might delineate the role of small rural hospitals in EMS care.

q Federal EMS Technical Assistance

-Option 5: Congress could fund DOT and DHHS toaugment technical assistance to State EMS offices.

. Federally Sponsored EMS Research and Demonstra-tion programs

--Option 6: Congress could fund DOT and DHHS toaugment their EMS research and demonstration programsand encourage the investigation of EMS problems unique

to rural areas and providers. The research efforts of DOT’sNational Highway Traffic Safety Administration, andDHHS’s National Center for Health Services Researchand Centers for Disease Control, could be coordinated toaddress a broad range of outstanding research questions.

. Federal Incentives for Planning and EMS SystemsDevelopment

-Option 7: Congress could augment support of existing Federal programs that address EMS, namely the

DHHS Preventive Health Block Grant program andDOT’s State and Community Highway Safety Grantprogram. Consideration could be given to earmarkingfunds within these grant programs for EMS.

-Option 8: Congress could establish a new EMScategorical grant program within DHHS.

. Targeting EMS Resources to Rural Areas

-Option 9: To accommodate the diversity of ruralareas, any Federal EMS resources provided to States

could be tied to implementation of a comprehensive Stateplan that addresses that State’s rural EMS systemproblems.

-475–



Appendix I--Organizational Charts .477

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Appendix J

Glossary of Terms

Access: Potential and actual entry of a population into thehealth care delivery system.

Accounts receivable: The full amount of patient care

beneficiary more than the applicable deductible andcoinsurance amounts. For physicians and supplierswho do not accept assignment, payment is made by



pcharges owed to a hospital or other health care facility.Average days in accounts receivable refers to theaverage number of days it takes a hospital or otherfacility to collect the full amount of patient carecharges.

Accreditation by JCAHO: A statement by the JointCommission on the Accreditation of Healthcare Organi-

zations (JCAHO) that an eligible health care organiza-tion, such as a hospital, complies wholly or substan-tially with JCAHO standards.

Acute care: Services within a hospital setting intended tomaintain patients for medical and surgical episodiccare over a relatively short period of time.

Admissions: Number of patients, excluding newborns,accepted for hospital inpatient service during a particu-lar reporting period (American Hospital Associationdefinition).

Allowed (or allowable) charge (under Medicare): See customary, prevailing, and reasonable charges.

Alternative facility licensure: The process by which aState creates a new category of licensed health carefacility or new licensure rules for existing categories of facilities for the purpose of maintaining the viabilityand accessibility of certain facilities or services.

Ambulatory care: Medical services provided to patientswho are not inpatients of hospitals. It includesoutpatient hospital care.

Ambulatory surgery: Scheduled surgical services pro-vided to patients who do not remain in a hospitalovernight. The surgery may be performed in hospitaloperating suites or procedure rooms within a freestand-ing ambulatory care center.

Ancillary services or technology: Medical technologyor services used directly to support basic clinicalservices, including diagnostic radiology, radiationtherapy, clinical laboratory, and other special services.

Antitrust laws: Laws such as the Clayton Act (15 U.S.C.12-27) that prohibit institutional mergers and acquisi-tions, exclusive contracts, joint ventures, and otherbusiness dealings in areas that may substantiallyreduce competition or have the tendency to produce amonopoly, and consequently have a detrimental effecton consumer welfare.

Assignment: A process whereby a Medicare beneficiaryassigns his or her right to payment from Medicare tothe physician or supplier. In return, the physician or

supplier agrees to accept Medicare’s reasonable or allowed charge as payment in full for covered services.The physician (or supplier) may not charge the

p g , p y yMedicare directly to the beneficiary, who is responsi-ble for paying the bill. In addition to the deductible andcoinsurance amounts, the beneficiary is liable for anydifference between the physician’s actual charge andMedicare’s reasonable (allowed) charge.

Average length of stay: Average stay of hospital patientsfrom admission to discharge during a particular

reporting period; derived by dividing the number of inpatient days by the number of admissions for theperiod.

Bad debts: Patient care charges owed to a facility that thefacility considers to be largely uncollectable.

Balance billing: In the Medicare program, the practice of billing a Medicare beneficiary in excess of Medicare’sallowed charge. The “balance billing” amount wouldbe the difference between Medicare’s allowed chargeand the physician’s (or other qualifying provider’s)

billed charge. (See customary, prevailing, and reasonable charges; allowed charge; and billed charge.)

Billed charge: In the Medicare program, the physician’s(or supplier’s) actual (billed) charge for a service.Compare with customary, prevailing, and reasonable charges.

Birthweight: The weight of an infant at the time of delivery.

Board-certified physician: A physician who has com-pleted requirements of advanced training and practicein a particular medical specialty and has passedexaminations offered by the national certifying boardfor that specialty.

Breakeven financial status: The point in operations atwhich a business (e.g., health care facility) neitherloses money nor makes a profit.

Capital expenditures: The costs (including borrowingcosts) of purchasing a capital asset (e.g., plant,equipment).

Carrier (Medicare): See Medicare intermediaries or carriers.Case mix: The relative frequency of admissions of

various types of patients, reflecting different needs forhospital resources.

Certificate of Need (CON) laws: A certificate requiredby State law and issued by the State Health Planningand Development Agency to an individual or organiza-tion proposing to constructor modify a health facility,or offer a new or different health service. CON

recognizes that the proposed facility is needed (i.e., itdoes not create an excessive supply of services or addunnecessary costs to the health care system).

-478-

Appendix J--Glossary of Terms q 479

Certification by HCFA: A statement by the Health CareFinancing Administration (HCFA) that a hospital orhealth care institution meets HCFA’s conditions of participation. Certification by HCFA is required for

Medicare and Medicaid reimbursement.Certified Rural Health Clinic (RHC): A facility (or part

f f ili ) d i l i h i i f

number of hospitals regardless of the actual or practicalmeans (e.g., roads) available to travel between thesehospitals.

Customary, prevailing, and reasonable (CPR) chargemethod (Medicare): The method used by carriers todetermine the approved charge for a particular Part B

i f P i l h i i li b d



of a facility), engaged mainly in the provision of outpatient primary medical care, that is eligible toreceive cost-based Medicare and Medicaid reimburse-ment primarily by virtue of its: (1) location in aCensus-defined rural health manpower shortage area(HMSA) or medically underserved area (MUA), and(2) employment of at least one midlevel practitioner

(i.e., physician’s assistant, nurse practitioner, or nurse-midwife).Community Health Centers (CHCs): Health care facili-

ties funded by the U.S. Department of Health andHuman Services to provide comprehensive primaryhealth services in both rural and urban areas wherethere are shortages of medical personnel and services.

Community Mental Health Center (CMHC): Anorganization (or affiliated group of organizations), thatreceived Federal funding under the Community Men-

tal Health Centers Act of 1963 to make available acomprehensive set of community-based mental healthservices, including emergency and outpatient care,consultation and education, and partial and completehospitalization.

Computed Tomography (CT) scanner: A diagnosticdevice that combines X-ray equipment with a com-puter and a cathode ray tube (television-like device) toproduce images of cross-sections of the body.

Congenital abnormality or anomaly: Any abnormality,whether genetic or not, that is present at birth.

Contiguous area: As it relates to HMSAs, an area inclose proximity to an area under consideration fordesignation as a HMSA (proximity is based on traveltime from the population center of the service area tothe center of the contiguous areas).

Continuity of care: Medical care that proceeds withoutinterruption across time and across different sites andlevels of care.

Contract-managed hospitals: General daily manage-ment of a hospital by another organization under aformal contract. Managing organization reports di-rectly to the board of trustees or owners of the managedhospital. The managed hospital retains total legalresponsibility and ownership of the facility (AmericanHospital Association definition).

Cooperative or alliance of hospitals and other facili-ties: A formal organization working on behalf of itsindividual members for specific purposes (e.g., sharing

of services, development of staff education programs,legislative advocacy).

“Crow-fly” miles: A ten-n used to describe the straight-line or shortest distance in miles between a given

service from a Particular physician or supplier based onthe actual charge for the service, previous charges forthe service by the physician or supplier in question, andprevious charges by peer physicians or suppliers in thesame locality. Customary charge: In the absence of unusual medical circumstances, the maximum amountthat a Medicare carrier will approve for payment for a

particular service provided by a particular physicianpractice. The carrier computes the customary chargeon the basis of the actual amount that a physicianpractice or supplier generally charges for a specificservice. Prevailing charge: In the absence of unusualmedical circumstances, the maximum amount a Medi-care carrier will approve for payment for a particularservice provided by any physician practice within aparticular peer group and locality (see “prevailingcharge locality”). Generally, this amount is equal tothe lowest charge in an array of customary charges thatis high enough to include 75 percent of all the relevantcustomary charges. Approved or reasonable charge:An individual charge determination made by a Medi-care carrier on a covered Part B medical service orsupply. In the absence of unusual medical circum-stances, it is the lowest of: 1) the physician’s orsuppliers’ customary charge for that service; 2) theprevailing charge for similar services in the locality; 3)

the actual charge made by the physician or supplier;and (4) the carrier’s private business charge for acomparable service. Also called allowed charge orreasonable charge.

Day treatment: A specialized and intensive form of mental health service, less restrictive than inpatientcare, in which the partially hospitalized patient re-ceives treatment for 5 to 6 hours a day.

Degree of shortage: See Priority groups.

Diagnosis-Related Groups (DRGs): Groupings of diag-nostic categories drawn from the International Classi-fication of Diseases and modified by the presence of asurgical procedure, patient age, presence or absence of significant comorbidities or complications, and otherrelevant criteria. DRGs are the case-mix measuremandated for Medicare’s prospective hospital pay-ment system by the Social Security Amendments of 1983 (Public Law 98-21).

Direct reimbursement: Payment for services that is

submitted directly to the health care practitioner whoprovided those services.

Downsizing (of hospitals and other health care facili-ties): Taking actions such as reducing the number of


beds and staff with the goal of reducing expenses inorder to cope with diminished demand for services.

DRG outliers: Cases with unusually high or low resourceuse. Defined by the Social Security Amendments of

1983 (Public Law 98-21) as atypical hospital cases thathave either an extremely long length of stay orextraordinarily high costs when compared to most

Fixed costs: An operating expense that does not vary, at

least over the short term, with the volume of servicesprovided.

Freestanding facilities: Facilities that are not physically,

administratively, or financially connected to a hospi-tal, such as a freestanding ambulatory surgery center.

Frontier counties: Counties with population densities of



extraordinarily high costs when compared to mostdischarges classified in the same diagnosis-relatedgroup. (See Diagnosis-Related Groups)

Electronic fetal monitoring: Continuous monitoring of the fetal heart rate and uterine contractions through theuse of an electrode and an amniotic fluid catheter andpressure transducer attached to the mother’s abdomen.

This process is used to detect abnormal fetal cardiacpatterns during labor and delivery.Endowments: Funds established by an institution to

accept monetary contributions from private sources.Essential Access Community Hospital (EACH): A

newly designated type of rural hospital created byCongress in 1989 (Public Law 101-239). Limited tohospitals in only a few States, EACHs will be facilitiesof at least 75 beds that provide backup to Rural

Primary Care Hospitals as part of a patient referral

network Designated facilities will automatically qual-ify for Medicare’s payment rules for Sole Community

Hospitals.

“Evaluative and management services”: Services,

such as office visits, that may involve but do notdepend in a major way on any medical devices.

Expenses per inpatient day: Expenses incurred forinpatient care only, derived by dividing total expensesby the number of inpatient days during a particular

period (American Hospital Association definition).Extracorporeal shock wave lithotripsy (ESWL): A

technique for disintegrating urinary tract stones thatuses shock waves generated outside a patient’s bodyand does not require a surgical incision.

Federal Tort Claims Act (FTCA): Enacted in 1946 [28U. S.C.A. sec. 1346(b) (Supp. 1988)], the FTCA allowsan injured party to sue the United States Government.

Fee schedule (for physician services): An exhaustive listof physician services in which each entry is associatedwith a specific monetary amount that represents theapproved payment level under a given insurance plan.

Fertility rate: The annual number of live births per 1,000women of childbearing age (15 to 49 years) in adefined population as a proportion of the estimatedmid-year population of women 15 to 49 years of age.

Fetal death: The product of conception which, afterseparation from its mother, does not breathe or showother signs of life required to meet the World Health

Organization’s criteria for a live birth. Compare live birth.

Fetal mortality ratio: The annual number of fetal deathsas a proportion of the annual number of live births.

Frontier counties: Counties with population densities of 6 or fewer persons per square mile.

Geographic Practice Cost Index (GPCI): An indexused by Medicare and some researchers to examinedifferences in physician practice costs across geo-graphic areas. The index is based on per-unit costs.

Gross patient revenue: Consists of the full amount of revenue from services rendered to patients, includingpayments received from or on behalf of individualpatients.

Health Maintenance Organization (HMO): A healthcare organization that, in return for prospective percapita payments, acts as both insurer and provider of comprehensive but specified medical services. Adefined set of physicians provide services to a volun-tarily enrolled population. Prepaid group practices andindividual practice associations are types of HMOs.

Health Manpower Shortage Areas (HMSAs): Areas,population groups, and facilities designated by theFederal Government as having shortages of healthpersonnel. HMSAs, which are currently designated forprimary care, dental, and psychiatric personnel, aredetermined primarily by population-to-practitionerratios.

Health Manpower Shortage Area Placement Oppor-tunity List (HPOL): A list of the most needy HMSAs

used by the National Health Service Corps in the

placement of volunteer and obligated personnel.Hill-Burton program: A Federal program begun in 1946

to fund health facility construction in areas of needand foster coordination among health care facilities.

Hospital or health care facility cooperative/alliance:See Cooperative or alliance of hospitals and other

facilitiesHospital or health care district/authority: A geo-

graphic area created and controlled by a political

subdivision of a State, county, or city solely for thepurpose of establishing and maintaining medical careor health-related care institutions.

Index of Medical Underservice (IMU): The sum of the

weighted values of four indicators of unmet health careneeds in an area (i.e., infant mortality rate, percent of the population 65 and older, percent of the populationliving in poverty, and population-to-primary carephysician ratio) that is used to determine its status asa Medically Underserved Area. IMU values range

from O to 100, with lower scores indicating increasingmedical underservice.

Indirect reimbursement: A situation wherein a healthcare practitioner can be reimbursed for his or her

Appendix J--Glossary of Terms . 481

services, but can only obtain such reimbursementthrough the employing physician or health carefacility.

Infant mortality: Death in the first year of life. It includes

neonatal mortality and postneonatal mortality.Infant mortality rate: The annual number of deaths

among children less than 1 year old as a proportion of

ity include uterine hemorrhage, toxemia, and underly-ing medical conditions that complicate pregnancy suchas diabetes and infections (e.g., tuberculosis, syphilis).

Maternal mortality rate: The annual number of mater-

nal deaths related to pregnancy as a proportion of theannual number of live births.

Medicaid: A Federal-State medical assistance program



g y p pthe annual number of live births.

Inpatient care: Medical services provided to patientsadmitted to hospitals for overnight stay.

Inpatient days: Number of adult and pediatric days of care, excluding newborn days of care, in a hospitalrendered during a particular reporting period (Ameri-can Hospital Association definition).

Insufficient-capacity criteria: Criteria specific to pri-mary care and dental HMSA designations that signifythe inability to obtain health services in a timelyfashion (e.g., unusually long waiting times for appoint-ments, high percentage of area practitioners notaccepting new patients).

Intensive care: Hospital service units designed to meetthe special needs of patients who are seriously orcritically ill or who otherwise need intense and

specialized nursing care.Joint Venture: A relationship in which two or moreparties enter into a business as co-owners of a specificproject(s) to share in profits and losses.

Live birth: According to the World Health Organization,‘‘the complete expulsion or extraction from its motherof a product of conception, irrespective of the durationof pregnancy, which, after such separation, breathes orshows any other evidence of life such as beating of theheart, pulsation of the umbilical cord, or definite

movement of voluntary muscles. ” This definition isthe basis for most States’ requirements governing thereporting of live births. Compare fetal death.

Local health departments (LHDs): Municipal or countygovernment-operated facilities providing basic per-sonal and environmental health services.

Long-term care: Health care for nonacute conditions(e.g., convalescent care for a person with an extendedor permanent disability). Includes skilled nursing care(long-term care requiring the supervision and frequentservices of a skilled nurse) and intermediate care (theroutine provision of health-related care to individualsnot requiring skilled nursing care).

Low birthweight babies: Live births weighing less than5-½ pounds (2,500 grams).

Magnetic resonance imaging (MRI): A technique thatproduces images of the body by measuring the reactionof nuclei (typically of hydrogen protons) in magneticfields to radiofrequency waves.

Maternal mortality: Maternal mortality includes deathsdue to complications of pregnancy, childbirth, and thepuerperium (the period of 42 days following thetermination of pregnancy). Causes of maternal mortal-

p gauthorized in 1965 to pay for health care services usedby people defined as medically needy or categoricallyneedy. Categorically needy persons are low-incomeaged, blind, disabled, first-time pregnant women, orfamilies with dependent children. Medically needypersons are any of the above whose incomes are aboveeligibility limits for the categorically needy but who

have high medical expenses that reduce their resourcesbelow established limits.

Medically Underserved Areas (MUAs): Areas deter-mined by the Federal Government to have inadequateaccess to health care as determined by the Index of

Medical Underservice (IMU).Medically Underserved Populations (MUPs): Popula-

tions not meeting MUA criteria that are designated asundersexed based on unusual local conditions that

may affect the area/population.Medicare: A nationwide, federally administered healthinsurance program authorized in 1965 to cover the costof hospitalization, medical care, and some relatedservices for eligible persons over age 65, personsreceiving Social Security Disability Insurance pay-ments for 2 years, and persons with end-stage renaldisease. Medicare consists of two separate but coordi-nated programs-hospital insurance (Part A) andsupplementary medical insurance (Part B). Health

insurance protection is available to insured personswithout regard to income.

Medicare conditions of participation: Requirementsthat hospitals and other institutional providers mustmeet in order to be allowed to receive payment forMedicare patients. An example is the requirement thathospitals conduct utilization review.

Medicare intermediaries or carriers: Fiscal agents(typically Blue Cross plans or commercial insurancefirms) under contract to the Health Care FinancingAdministration for administration of specific Medicaretasks. These tasks include determining reasonablecosts for covered items and services, making pay-ments, and guarding against unnecessary use of covered services for Medicare Part A payments.Intermediaries also make payments for home healthand outpatient hospital services covered under Part B.

Medicare/Medicaid beneficiary: One who receivescoverage for health services under Medicare or Medi-

caid.Medicare operating margin: Revenues received by ahealth care provider from Medicare less the provider’soperating costs covered by Medicare payments, di-


vialed by Medicare revenues and multiplied by 100.

Medicare revenues and costs not covered underMedicare’s prospective payment system (e.g., capitalexpenditures, medical education costs) are excluded.

Merger (of health facilities): The union of two or moreformerly independent institutions under a single own-ership, accomplished by the complete acquisition of

to urban areas) to receive health care and otherservices.

Outpatient care: Services provided in a hospital and thatdo not include an overnight stay.

Outpatient surgery: See Ambulatory surgery.Overhead costs: Includes costs to a health care facilitythat are not direct labor (i.e., payroll expenses) such as

l f i b fi d h i di l



one institution’s assets or stock by another institution.Migrant Health Center (MHC): A center that receives

Federal funds to provide primary health care to migrantand seasonal farmworkers and their families.

Metropolitan Statistical Area (MSA): As defined by theU.S. Office of Management and Budget, an MSA is acounty or group of counties that includes either a city

of at least 50,000 residents, or an urbanized area withat least 50,000 people that is itself part of a county/ counties with at least 100,000 total residents.

Multihospital system: Two or more hospitals that areowned, leased, sponsored, or contract-managed by acentral organization (American Hospital Associationdefinition).

Negative operating margin: A loss that occurs whencosts of operation exceed revenues.

Neonatal intensive care unit (NICU): A specializedhospital unit combining high technology and highlytrained staff that treats seriously ill newborns.

Neonatal mortality rate: The annual number of neonataldeaths as a proportion of the annual number of livebirths.

Neonatal mortality: Death during the first 4 weeks of life.

Net patient revenue: For a hospital or other health carefacility, consists of gross patient revenue less deduc-

tions for contractual adjustments (amounts of patientcharges not paid by insurers), bad debts, charity, andother factors.

Net total revenue: Consists of net patient revenue plus allother revenue of a hospital or other health care facility,including contributions, endowment revenue, govern-ment grants, and all other payments not attributable topatient care.

Nonmetropolitan Statistical Area (NonMSA): Any

area not in an MSA.Obstetric care: Medical care received during pregnancy,labor and delivery, and the period immediately follow-ing birth.

Occupancy: Ratio of average number of inpatients(excluding newborns) receiving care to the averagenumber of beds in a hospital set up and staffed for use(i.e., statistical beds) during a particular reportingperiod (American Hospital Association definition).

Operating costs: The ongoing expense of operating a

health care facility.Outmigration: As used in this report, the movement by

rural residents outside their communities (particularly

employee fringe benefits and other expenses indirectlyrelated to patient care operations.

Partial hospitalization: A planned transitional programof mental health treatment services after psychiatrichospitalization or residential treatment when a patientno longer needs 24-hour care.

Patient margin: A measure of the profitability of patient

care, calculated as (patient care revenues minus totalcosts) divided by patient care revenues. See also net

patient revenues.Peer Review Organizations (PROS): PROS are organi-

zations established in 1982 (public Law 97-248) withwhich the U.S. Department of Health and HumanServices contracts to review the appropriateness of settings of care and the quality of care provided toMedicare beneficiaries.

Perinatal care: Medical care pertaining to or occurring in

the period shortly before or after birth; variouslydefined as beginning with the completion of the 20thto 28th week of gestation and ending 7 to 28 days afterbirth.

Perinatal mortality: Fetal and neonatal deaths com-bined.

Perinatal mortality ratio: The annual number of perina-tal deaths as a proportion of the annual number of livebirths.

Physician Payment Review Commission: A commis-sion established by the Comprehensive OmnibusBudget Reconciliation Act of 1985 (Public Law99-272) to make recommendations to Congress andthe Secretary of Health and Human Services on variousissues relating to changes in physician payment underMedicare.

Positive operating margin: A surplus that occurs whenrevenues exceed costs of operation.

Postneonatal mortality: Deaths that occur from 28 days

to age one.Postneonatal mortality rate: The annual number of postneonatal deaths as a proportion of the annualnumber of live births.

Preceptorship: An arrangement whereby a student takespart of his or her training under the supervision of anactive practitioner at that practitioner’s worksite. Forexample, an office-based physician in a rural area mayserve as a preceptor for a medical student, instructingthe student in the various aspects of rural medical

practice.Premature births: Babies born between 20 and 36 weeks

gestation. (also called preterm births)

Appendix J--Glossary of Terms q 483

Prenatal care: Medical services delivered from concep-tion to labor. Prenatal care and intrapartum carecombined are referred to as maternity care. Earlyprenatal care is care received in the first trimester of

pregnancy.Prevailing charge (Medicare): See Customary, prevail-ing, and reasonable (CPR) method.

P ili h l lit (M di ) A ti l

Rational service areas: To be proposed for HMSA

designation, an area must be “rational” for thedelivery of services based on criteria governing thesize and boundaries of the area and consideration of

such factors as established transportation routes andlanguage barriers.Relative Value Scale (RVS): A list of all physician

i t i i di l ki f th i



Prevailing charge locality (Medicare): A particulargeographic locality within which Medicare determinesprevailing charges and sets payment under Part B formedical services provided by physicians and otherqualifying health care practitioners. There are approxi-mately 240 separate prevailing charge localities in theUnited States.

Primary care: A basic level of health care, usuallyprovided in an outpatient setting, that emphasizes apatient’s general health needs.

Primary care physicians (as defined for HMSA desig-nation purposes): Family and general practitioners,general pediatricians, obstetricians and gynecologists,and general internists.

Priority groups: The ranking of designated HMSAs intofour groups according to population-to-practitionerratios and indications of high need and insufficientcapacity (group 1 HMSAs indicate greatest need).

“Procedural” services: Services that are dependent in asubstantial way on the use of a medical device.Contrast “evaluative and management services.”

Procedure (medical or surgical): A medical technology

involving any combination of drugs, devices, andprovider skills and abilities. Appendectomy, for exam-ple, may involve at least drugs (for anesthesia),monitoring devices, surgical devices, and the skilled

actions of physicians, nurses, and support staffs.Prospective payment: Payment for medical care on the

basis of rates set in advance of the time period in whichthey apply. The unit of payment may vary fromindividual medical services to broader categories, suchas hospital case, episode of illness, or person (capita-tion). Compare retrospective cost-based reimbursement.

Prospective Payment Assessment Commission(ProPAC): A commission established by the same law

that created the DRG-based prospective paymentsystem for Medicare (Public Law 98-21) to advise theSecretary of Health and Human Services on variousactivities needed to maintain and improve that pay-ment system.

Provider participation (in Medicare or Medicaid): Theprovision of care by a physician to patients who arecovered by either Medicare or Medicaid.

Quality of care: The degree to which actions taken or nottaken increase the probability of beneficial healthoutcomes and decrease risk and other untowardoutcomes, given the existing state of medical scienceand art.

services containing a cardinal ranking of those serviceswith respect to some conception of value, such that thedifference between the numerical rankings for any twoservices is a measure of the difference in value betweenthose services. (A “resource-based relative valuescale” will soon be used by Medicare for reimburse-ment of physician services.)

Reproductive-age women: Women between and includ-ing the ages of 15 and 44 years.

Respiratory Distress Syndrome (RDS): An acute respi-ratory disorder that in premature infants is thought tobe caused by a deficiency of pulmonary surfactant. Insevere form, patients often need mechanical assistanceto breathe.

Retrospective cost-based reimbursement: A paymentmethod for health care services in which hospitals (or

other providers) are paid their incurred costs of treatingpatients after the treatment has occurred. In thiscountry, the term has traditionally referred to hospitalpayment, since other providers have generally beenpaid on the basis of charges instead of costs.

Rural Primary Care Hospital (RPCH): A newlydesignated type of rural hospital created by Congressin 1989 (Public Law 101-239). Limited to hospitals inonly a few States, RPCHs will be small facilities thatprovide emergency and minimal inpatient care and will

be eligible for special reimbursement under Medicare(also see Essential Access Community Hospitals).

Rural Referral Centers (RRCs): Tertiary-care ruralhospitals, usually large, that serve a wide geographicarea. Hospitals that qualify as RRCs must meet certainsize and referral characteristics, and are eligible toreceive special considerations under Medicare’s pro-spective payment system.

“Safe harbor” regulations: Regulations proposed bythe U.S. Department of Health and Human Services

that would specify which practices of hospitals andother health care providers would not be unethicalunder the Medicare and Medicaid anti-kickback provi-sions.

Sentinel health events: Medical conditions that, byvirtue of their presence or prevalence in a population,indicate a lack of access to acceptable, quality primarycare services. Examples include dehydration in in-fants; measles, mumps, or polio in children; andadvanced breast cancer or invasive cervical cancer inadult women.

Skilled nursing facility (SNF): A facility that providesskilled nursing care (see long-term care). A “distinct-


part SNF” is a distinct unit within the hospital thatprovides such care (i.e., beds set up and staffedspecifically for this service), is owned and operated bythe hospital, and meets Medicare certification criteria.

Sliding fee scale: A schedule of discounts in charges for

services based on the consumer’s ability to pay,according to income and family size.

Sole Community Hospital (SCH): A rural hospital,ll ll h i d b h l f

long-term care services from its State health planningand development agency.

Tax appropriations: Subsidies available to health carefacilities from State or local government taxes.

Tax-exempt revenue bonds: Bonds generally are evi-

dence of a debt in which the issuer (borrower) promisesto repay the bond’s holder. A revenue bond is issuedby a government (borrower) to taxpayers (bondholder)



usually small, that is presumed to be the only source of local inpatient hospital care to area residents by natureof their isolated location, weather conditions, travelconditions, or absence of other hospitals. Federallydesignated SCHs receive special considerations underMedicare’s prospective payment system.

Strategic planning: A rational process by which an

health care organization (e.g., hospital) determines itsbest course of action. This involves effectively balanc-ing community needs for health services with theorganization’s strengths and ability to use availableresources, and producing practical plans to implementstrategies that are financially feasible and acceptable toconsumer needs (American Hospital Association defi-nition).

Sudden Infant Death Syndrome (SIDS): The suddenand unexpected death of an infant, for reasons thatremain unclear even after autopsy. SIDS is the mostcommon cause of death in the post-neonatal period.

Swing beds: Licensed acute-care beds designated by ahospital to provide either acute or long-term careservices. A hospital qualifying to receive Medicare andMedicaid reimbursement for care provided to swingbed patients must be located in a rural area (as definedby the U.S. Bureau of the Census), have less than 100acute care beds, and when applicable must havereceived a certificate of need for the provision of

to raise funds in anticipation of tax receipts, and thenrepaid from tax revenues once they are received. Mostbonds issued by governments are tax-exempt, that is,the bondholder pays no Federal income tax on interestearned.

Third-party payment: Payment by a private insurer orgovernment program to a medical provider for care

given to a patient.Total hospital margin: A measure of hospital profitabil-

ity, calculated as (total revenues minus total costs)divided by total revenues. Total revenues includeprivate contributions and public subsidies as well aspatient care and other revenue.

Ultrasound: High-frequency sound waves that can befocused and used to picture tissues, organs, structures,or tumors within the body. Ultrasound is particularlyuseful for in utero examinations of the fetus.

Uncompensated care costs: Deductions from patientcare revenues that are attributable to charity care and bad debts (for which the health care facility neverexpects to receive payment).

Unusually high-needs criteria: Criteria specific to thetype of HMSA (i.e., primary care, dental, psychiatric)that are indicative of an unusually high need formedical care (e.g., poverty rates, population withoutfluoridated water supply, and high prevalence of

alcoholism).



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659. U.S. Department of Health and Human Services,Health Resources and Services Administration,Bureau of Health Care Delivery and Assistance,Rockville$ MD, unpublished data on the NationalHealth Service Corps provided by G. Goubeau,Nov. 9, 1989.

660. U.S. Department of Health and Human Services,Health Resources and Services Administration,

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684.

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Health Resources and Services Administration,Bureau of Health Professions, Office of DataAnalysis and Management, A Report to Congress:

On the Evaluation of Health Manpower Shortage Area Criteria, ODAM Report No. 2-84 (Rock-

ville, MD: HRSA, September 1983).U.S. Department of Health and Human Services,Health Resources and Services Administration,Bureau of Health Professions, Office of DataAnalysis and Management, Diffusion and theChanging Geographic Distribution of PrimaryCare Physicians DHHS Pub. No. HRS-P-OD-84-1(Rockville, MD: HRSA, June 1983—revised No-vember 1983).U.S. Department of Health and Human Services,

Health Resources and Services Administration,Bureau of Health Professions, Office of DataAnalysis and Management, “SelectedStatistics onHealth Manpower Shortage Areas as of June 30,1985,” Rockville, MD (no date).

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688.

689.

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691.

692.

693.

694.

695.

696.

697.

ville, MD: OMCH, 1989).U.S. Department of Health and Human Services,Health Resources and Services Adrninistmtion,Office of Rural Health Policy, “Office of RuralHealth Policy Public Information,” unpublisheddocument, April 1989.U.S. Department of Health and Human Services,Health Resources and Services Administration,Office of Rural Health Policy, Roclwille, MD,“National Health Service Corps Scholarship Pro-gram White Paper,” unpublished document, Jan.18,1990.

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37 Rural Hospitals Closed in 1987 (Washington,

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A Prospective Payment System (Washington, DC:OIG, July 1989).U.S. Department of Health and Human Services,Public Health Sewice Expert Panel on the Content





Index



Index

Index

Accidents and accident prevention

migrants, 80

seatbelts, 43, 54urban V. rural, 43,54

Acquired immune deficiency syndrome, 298,304Acute disease, 43,45

elderly, 57migrant workers, 53

see Emergency and acute careAdministration and administrators

community health centers, 160-161, 182Federal, 14,24-25,75,76,81h i l 82 113 160 161

American Optometric Association, 274

Anesthetists, 250,257-259,322,340Anti-Drug Abuse Act of 1988,77Antitrust law, 186-188, 189, 190-192, 193

Appalachia, 41,411Area Health Education Centers (AHECs), 21-22,78, 100,299,

301,343-346,361,362, 367,373,374Arizona, 93,344,366,397

personnel supply/demand, 251,255,267,274,275, 391Arkansas, 92,93, 105,344,397Association of American Medical Colleges, 226Attitudes



hospital, 82, 113, 160-161Medicaid, State role, 68-70,74,98, 105Medicare, 181

record technicians, 278, 280, 283State-level, 24,68,89-91,96-97,98, 99-101, 104, 106see also R egula t ions

Adoles cen t s , 95,427Age factors, 6,38,40-41

dentists, 270insurance coverage, 48physicians, 247-248,282regional distributions, 42, 50, 54, 55, 56

urban v. rural, 54

see also Children; ElderlyAgencies on aging, 172, 174Agency for Health Care Policy and Research, 9,61,82Agriculture, 41,42,46,418

Department of Agriculture, 41Farmers Home Administration, 14, 139-140,205

see also Migrant workers

AIDS, 298,304 Aid to Families with Dependent Children, 68-69,70

Alabama, 168, 190,342,407

Alaska, 337,344

Alcohol abuse, 418,424 Alcohol, Drug Abuse, and Mental Health Administration, 76,

420 Alcohol, Drug Abuse, and Mental Health block grant, 9,61,62,

76-77,419,420 Allied health professionals, 19,80, 188,332

definitions, 275,279-280

education, 21-22,275, 280-281283, 284, 330, 342, 373licensing, 281,330 mental health, 27,431 multiple competencies, 21-22, 280-281, 284, 330, 342

recruitment and retention problems, 330, 331, 360supply/demand, 275, 277-278,282-283,371see also Lab technicians; Radiologists; Record technicians

Allopathic medicine, 220,225,232,249,318, 323-324Ambulatory services, see Outpatient services

American Academy of Family Physicians, 229,398,399,412American Academy of Nurse Practitioners, 251

American Board of Family Practice, 226American College of Nurse-Midwives, 255,320American College of Obstetricians and Gynecologists, 398American Hospital Association, 111, 165-166,278

American Medical Association, 226,230,275,319,329American Nurses Association, 341

alternative delivery models, acceptance of, 212interprofessional prejudice, 212, 375,433personal health status, 43,47,57professional career choices and, 315,316-319,322-323, 331

Audiologists, 280Automobiles, 43

Beliefs, see AttitudesBlack Americans, 40,380,387,388,389-390Black lung disease, 80Block grants, 9,28,61,62,75-77,90-91, 214,400,404-405,411,

412,419,420,433Border Health Education Centers, 78

Bureau of Health Care Delivery and Assistance, 79, 183,293,354,357,366,419,420Bureau of Health Professionals, 25,106,243-244,273,301, 324,

335,362-363,365

California, 16,93, 189, 191,201-202,203,205, 206-207,411Canada, 229,231Capital investments

equipment, 92,93, 114,329,409hospitals, 14,137-140,162,188-189, 191,192-193,203,205,

413

Medicare and, 64,65state financing, 103, 104

Career choice, professionals, 315,316-319,322-323, 331Census Bureau, 35,38,40Central U.S., 150,238,242,243,260, 371,407Certificates of need, 188-189, 191, 192-193,203,205Certification, see Licenses and permitsCertified nurse-midwives, see Midwives

Charitable organizations, 189

see also Volunteers and volunteeringChildren

adolescent health services,95,427disabled, 75education, 318

immunization, 43,47, 75,76infant mortality, 25,26,80,288,293,298, 304,305,379,380,

387,412mental health, 418pediatric dentists, 270,271,272screening, 70, 75,411see also Maternal and infant care

Cholesterol, 76

Chronic disease, 5,6,43,45,46,54, 198,305AIDS, 298,304

–517–


black lung disease, 80of elderly, 57

hemophilia, 75hypertension, 53,76

of migrant workers, 53renal, 64, 65

Clayton Act, 185

Clergy, 430-431Clinics, see Community and Migrant Health Centers; Commu-

nity health centers; Rural health clinics; Satellite clinicsColorado, 160, 169,202,203,320,391Committee on Labor and Human Resources, 5

Community and Migrant Health Centers (C/MHC), 8,9,12,13,14,361

Delaware, 71,93Demography, 5-7,35-60

age factors, general, 6, 38, 40-41, 42, 48, 50, 54, 55, 56,247-248,270,282

Census Bureau, 35,38,40definitional issues, 35,37,38,4041,53-54, 73,298elderly, 40-41, 50-52, 54, 55, 56-58, 145, 172, 174, 205,

247-248,270,293,305epidemiology, 82hospitals and, 6, 13,37, 111-113, 117-120, 121, 143-144low-density areas, access issues, 6,13,37,118-120,144-145,

150, 153, 168,213migrant workers, 52-53,54-55,59,78,80, 83, 104,298minority groups, 6,40,53,54,78,79,83, 272-273,298,304,



maternal and infant cam, 24-25, 398,405,407

mental health services, 28

National Health Service Corps, 357-358,360-361,368research, 17

standards, 13

Community health centers, 79-80,124-128, 129, 151,152-153,158-159, 160, 172-173, 174, 183, 192, 197,211,

administration, 160-161, 182mental health, 28,76,419,432economic factors, 140-142, 145-146

underserved areas, designation, 293, 299,306,308

Community mental health centers, see Mental health servicesCommunity Mental Health Centers Act, 76,418419

Community Support Program, 420,421422Comprehensive Alcohol Abuse and Alcoholism Prevention,

Treatment, and Rehabilitation Act, 76

Computer sciencedatabases, 26,397telecommunications, 337,346-348,409

Conferences and meetingsmental health, 419-420midlevel practitioners, 24

Cooperatives, 169-172, 198

Coordination, 15-17,213-214multifacility alliances, 12, 124, 144, 161, 169-175, 177, 212State role, 89-91,94-95,96-97,98, 100-101, 104,204-205

Corporate restructuring, 167-168

costsambulatory surgery, 13,67,80, 134-136community health centers, 141-142

education, professional, 63, 64, 64, 323-325, 331, 338, 374,

423hospitals, 10, 17, 124, 131-137, 138, 158-159, 164

licensing, 188

Medicaid, prospective payment, 71, 164Medicare, prospective payment system, 61-66,132-134,158,

164,213physician practice, 329; see also Malpractice insurance

State systems, 103Counseling services, 424,427

self-help groups, 431

Court cases, see LitigationCrime and criminals

fraud, 13, 14-15, 184-185, 192

rape, 76

Criteria, see Standards

Databases, 26,397

316,335,380,387,388, 389-390,411mortality, 5, 25, 26,43,44, 54, 80, 288, 293,298, 304, 305,

309,379,380,387,412outmigration, 12, 17, 37-38,78, 146-147, 153,211professional personnel, supply, 5,8, 17-19,20,25, 116,145,

219-284, 309-310, 311, 318, 319, 371-376, 390-400,426-431

research, 83State-level data, 39,40transition grants, 81underserved areas, 61, 126, 150, 287-311, 361, 362, 372; see

also Health Manpower Shortage Areas

see also Geographic factors; Income, personal; Metropolitan

areas; Poverty; Regional trends; Sex differencesDemonstration projects, 17

Area Health Education Centers, 21-22,78, 100,299,301elderly abuse prevention, 174

hospitals, alternative, 201-202,211-212

maternal and infant care, 26-27,75,396,410412medical schools, 93mental health care, 29,420,421, 433-434networks, 214

swing bed, 73-74, 105

Dentists and dentistry, 19,22,47-48,50,80education, costs, 423Health Manpower Shortage Areas, 286,291,294hygienists, 277,279Medicaid, 73pediatric, 270,271,272supply/demand, 268-272,283

Department of Agriculture, 41

Department of Health and Human Services, 82,125,185,199

coordination, 17

essential services criteria, 14, 16

genetic screening, 75health care networks, 15-16, 17,214legislative models, 24physician bonus payment program, 24-25,303,350-351,361,

367,374underserved areas, 61, 126, 150; see also Heal th M anpower

Shor tage Areas

s e e also Medicaid; Medicare; Medically Underserved Areas;

specific administrative subunitsDepartment of Health Education and Welfare, 287-288,291Department of Housing and Urban Development, 14,205

Department of Justice, 185Diagnosis, 80, 167, 198,201,330

Medicaid, 70,71

Index q 519

Medicare, 16,52,70,61-66physician opinions, 52,71,318prospective payment system, 16,61-66

screening, 43, 70,75, 80, 167,411,432Dietitians, 279-280

Dillon’s Rule, 190Disabled persons, 6

children, 75

Discharge planning, 73,214Diseases and disorders

migrant workers, 53, 59parasitic, 53,80substance abuse, 9,61,62,76-77,163,298, 419,422-424,426see also Acute disease; Chronic disease

tax exemptions, 167, 183-184, 189-190, 192, 193

underserved areas, criteria, 287-291,296,298,301, 303-311,362,372

see also Licenses and permitsEmergency and acute care, 5,12,76,80,81,114,116, 145,153,

162,204Health Manpower Shortage Areas, 298intensive care, 114, 115, 409,410,411Medicaid/Medicare, 73,211

mental health services, 422State action, 91, 105, 198,201,202,203swing bed program, 73-74, 105, 163-165, 166, 177, 182, 189technicians, supply/demand, 278,280

see also Essential Access Community Hospitals



;Drug abuse, see Alcohol abuse; Substance abuse

Eastern U.S., 53,238,318Economic factors, 6,42,54

affordability of health care, 5

antitrust, 185-188, 189, 190-192, 193

assessment of, 94community health centers, 140-142, 145-146

cooperatives, 169-172, 198corporate restructuring, 167-168

depression, 293efficiency, hospitals, 145, 158, 162-177, 187,213-214

hospitals, 8,10-12,17,111,113,123 -124, 130-140,142-146,152, 158, 159, 160-177, 187, 188,211-214licensing, 188mental health, 418

mergers, 175-176, 185-187, 192personnel recruitment and retention, 22-23,24,77,92,93,98,

183,185,242,282,323-329, 331-332,348-351,359, 361,362,363-366,367,374-375

regional trends, 41,42uncompensated care, 5,10, 130,131, 132,135, 140, 157,211,

329, 332; see also Uninsured patients

see also Antitrust law; Costs; Financing arrangements;Funding; Income, personal; Market forces and marketing;

Poverty; Revenues; Taxes

Education,patient, 62, 174,432public, 21-22,80,314,318see also Professional education

Efficiency, hospitals, 145, 158, 162-177, 187,213-214Elderly, 40-41,50-52,54,55,56-58, 145,205

agencies on aging, 172, 174

dentists, 270physicians, 247-248retirement counties, 41

underserved areas, 293, 305urban V. rural, 4041,50-52,54,55,56see also Medicare

Eligibilityacute-care hospitals, 201

community health centers, 80Essential Access Community Hospitals, 204,214maternal and child health grants, 75, 404, 406

Medicaid, 68-70,73-75,404,406Medicare, 73-75, 181-182,204National Health Service Corps, loan repayments, 22,77-78,

287,299,351,352-354, 356

see also Essential Access Community HospitalsEmergency Health Personnel Act and Amendments, 287,352

Employment and unemployment

allied health personnel, 278,280,281,282career choice, 315, 316-319, 322-323, 331

county classifications, 41government, 41, see also National Health Service Corps

hospitals, 116, 117, 158

hours of work, women, 229,317,318,329insurance coverage and, 4344,49leave, 93,348nurses, 24,73,74,259-263,264-268, 270,320,321,322,324satisfaction with job, nonphysicians, 322-323, 331

satisfaction with job, physicians, 318trends, 42

undersexed areas, designation criteria, 304, 305

urban v. rural, 41

vacation, 348

see also Migrant workers; Recruitment and retention; Wagesand salaries

Environmental health, 80

toxic substances, 53,75,76Epidemiology, 82

fetal and infant health indices, 380-387,390,391

mental disorders, 417-418,419,420State collection efforts, 24-25underserved area indices, 309

see also Mortality

Equipment, 92,93,329acute cam, 114ultrasound, 409

Essential Access Community Hospitals, 13,65,204,207,212,214

Essential services, 13-15, 16, 167,197-199,211-212criteria, 13-15,66, 198, 204, 213see also Emergency and acute care; Sole Community

Hospitals

Evaluation

National Health Service Corps, 358see also Needs assessment; Quality control; Standards

Exceptional Financial Need Scholarship Program, 335Exercise, 43

Facilities, see Community and Migrant Health Centers; Com-munity Health Centers; Hospitals; Multifacility alliances;

Rural health clinics; Satellite clinicsFamilies and householdssize, fee scales, 80spouses of practitioners, 317-318,331


two-parent, Medicaid eligibility, 69

see also Children

Family practitioners, 226, 229, 230, 233, 245, 316, 317, 335,339,341,397-399,412

Fanners Home Administration, 14, 139-140,205

Farming, see Agriculture; Migrant workersFederal Housing Act, 138

Federal Improved Child Health Program, 411

Federal Loan Repayment Program, 22,77-78,352-354,356, 368Federal role, 5,8-10, 13,61-83

administrative, 14,24-25,75,76,81antitrust, 185-188

community health centers, funding for, 8, 79-81, 124-128,129, 140-141, 142, 160-161

Florida, 93, 169,202-203,205,281, 330,366,397Fluoridation, 76

Forecasting, see ProjectionsForeign medical graduates, 229,231,247,248Fraud, 13, 14-15, 184-185, 192

Fundingcommunity centers, Federal, 8,79-81,124-128,129, 140-141,

142, 160-161

education, professional, 9,20-21,335,339-340, 352-358essential services facilities, 14Federal, 8-10, 14, 15-16, 22-27, 28-29, 77-83, 89-90, 106,

119, 137-138, 139-141, 160-161, 204, 335, 338-348,352-358,419,420, 433; see also Block grants

local, 157



9, 0 , , 60 6education, professional, 9,20-22,24,28,78-79, 301,316,335,

338-348,351-359essential services criteria, 13-15, 66, 198, 204, 213funding, 8-10, 14, 15-16, 22-27, 28-29, 77-83, 89-90, 106,

119, 137-138, 139-141, 160-161, 204, 335, 338-348,352-358,419,420, 433; see also Block grants

hospitals, assistance, 9, 13-14, 119-120land ownership, 41

licenses and permits, 14, 16, 126-129, 192local systems, relation to, 10, 197

malpractice, 26,396-398maternal and infant care, 9,25-27,61,62,75-76, 80,396,404,

411,412mental health services, 9, 28-29, 76-77, 418420,433-434migrant health centers, 53, 55, 59, 80; see also Community

and Migrant Health Centers

planning, 16-17,214policy, 9, 15, 16, 17,61,82-83recruitment and retention, general, 372-376regulations, 181-188, 192, 199-200,211, 212

research, 9, 17,61, 82-83,420standards, 17, 119, 192, 199-200State relation to, 10,14,15,23-24,75,87, 89-90,93,101,106,

301,302,303-308,311, 361,362,368student loan repayments, 22, 77-78, 287, 299, 301, 351,

352-354,356,357,368, 431technical assistance, 9, 10, 14, 15, 25,26, 27,212see also Health Manpower Shortage Areas; Legislation,

specific Federal; Medicaid; Medically Underserved Areas;

Medicare; National Health Service Corps; specific agencies and departments

Federal Tort Claims Act, 26,397, 398Federal Trade Commission, 185, 186Fertility, 388Financing arrangements

cooperatives, 169-172, 198corporate restructuring, 167-168hospitals, 130-140, 145, 158, 159, 166-177, 185, 187-188,

202,212,319Medicaid, 68,71-73,205Medicare, 16,61-66,82, 132-134, 158, 164,202,348-350mergers, 175-176, 185-187, 192Omnibus Budget Reconciliation Acts, 16,83,74,75,78,81,

83,338,340,348,350,419

research, 82State-level, 100, 103, 104

see also Capital investments; Costs; Health Care FinancingAdministration; Malpractice insurance; Public assistance

local, 157networks, 15-16, 17, 214

State, 23-24,89-91,93,100,105 -106, 130-131,133,363,365,428,433

statistics, 25see also Public assistance; Student aid

General Accounting Office, 75,400General practitioners, 226, 229, 233, 245, 268, 270, 317,

393-394,395,397Geographic factors, 146-151

antitrust, 186, 190, 193essential services criteria, 14,204,213

hospitals, 118-120, 144-151, 150, 153,213,412low-density areas, access issues, 6,13,37,118-120,144-145,

150, 153, 168,213Medicare, 83, 146, 150mental health services, 27,426,422,428midwives, 257nurse distribution, 251, 260-268

optometrists, 274, 276, 277

physician assistants distribution, 252-255physician distribution, 238,242,242,243,337remote areas, 15, 17, 213

State distribution efforts, 361-366

underserved areas, 61, 126, 150, 287-311, 361, 362; see alsoHealth Manpower Shortage Areas

see also Demography; Metropolitan areas; Regional trends;State-level action; Sole Community Hospitals; Transpor-

tation

Georgia, 190,341,397personnel supply/demand, 246-247,251,274

Government role

as employer, 41

facility collaboration with, general, 197-207see also Federal role; Local systems; State-level actionGraduate Medical Education National Advisory Committee,

220,242

Handicapped persons, see Disabled personsHawaii, 95,366Health Care Financing Administration, 24-25,81,182,200,202,

203,350Health Careers Opportunity Programs, 335Health education, see Education; Professional education

Health Education Assistance Loan Program, 335Health insurance, 43-46,48,49,80elderly, 50-51income level and, 44, 46,49, 54

Index q 521

maternal and infant care, 401-404

midlevel practitioners, 320, 322nurses, 322physician income, source of, 326uninsured, 5, 6-7, 50, 54, 82, 105, 211, 213, 305, 331, 390,

400,401403see also Health maintenance organizations; Medicaid; Medi-

careHealth Maintenance Organization Act, 291Health maintenance organizations, 21,129,170,229,255,274,

291,319,320see also Medically Underserved Areas

Health Manpower Shortage Areas (HMSAs), 8, 9, 22, 23,79,126,282,287-291,293-294, 295,371,372,375

financing arrangements, 130-140, 145, 158, 159, 166-177,185, 187-188,202,212,319

fundraising, local, 157geographic factors, 118-120, 144-151, 150, 153,213,412intensive care, 114, 115,409,410,411

licenses and permits, 16,73-74, 162, 187-188, 192, 199-204local efforts, 113, 131, 133, 175-176, 190,205-206long-term care, 114, 116, 143, 152

maternal and infant care, 407-409,410,412-413Medicaid, 70-71,72,73-74,118,131, 138-139,184-185,201,

212

Medicare, 16, 51-52, 62-66, 73-74, 118, 120-121, 13.0-135,138-139,181-182,184-185, 192,199-200,201,202, 211,212



Federal designation, 287,288-291,296,298, 301,303-311Medicaid, 74

Medicare and, 24-25,67,68,74,303,320, 350-351,361,367,374

mental health cam, 286, 291, 294midlevel practitioners, 320-321

National Health Service Corps, 77,296, 298-299,301, 303,309,352,354-356,358, 368,375

State role, 301,302,303-304,303-308, 311,361,362technical assistance to, 94

volunteer program, 77, 78,296, 299, 354, 357, 358, 368Health Resources and Services Administration, 25,75,79,80,

see also Health Manpower Shortage Areas; MedicallyUnderserved Areas

Health Services block grant, 9

Hemophilia, 75Hill-Burton Act, 118-120, 132, 137-138Hispanics, 53,78,83Historical perspectives

demography of U.S., 37-38

economics, 42-43Health Manpower Shortage Areas, 287-288

Medically Undersexed Areas, 291,293

research, 82Home care services, 80, 182, 198

Medicaid, 70

preventive, 76Hospitals and hospitalization, 80, 111-124, 151-152

administration, 82, 113, 160-161AHA, 111, 165-166,278allied health personnel, employed by, 278,280alternative models, 199-204,206-207,211-212antitrust law, 186-188, 189, 190-192, 193capital investments, 14,137-140,162,188-189, 191,192-193,

203,205,413closures, 142-146, 153, 319,408cooperatives, 169-172, 198

costs and cost containment, 10, 17, 124, 131-137, 138,158-159, 164

demography, general, 6, 13, 37, 111-113, 117-120, 121,143-144

discharge planning, 73,214diversification, 162-163, 167-168, 190, 192-193economic factors, 8, 10-12, 17, 111, 113, 123-124, 130-140,

142-146, 152, 158, 159, 160-177, 187, 188,211-214efficiency, 145, 158, 162-177, 187, 213-214elderly, 51-52,58, 145Federal assistance, 9, 13-14, 119-120

mental health, 163,421, 422,426mergers, 175-176, 185-187, 192, 212multifacility alliances, 12, 124, 144, 161, 169-175, 177,212nurses, employed by, 259-260, 265, 266, 267-268, 270nurses, State regulation of, 188, 189

outmigration and viability, 12, 146-147, 153, 211,407,409

ownership, 111, 113, 138, 185physicians, associations with, 166-167, 176-177, 185, 197-

189, 192,319planning, 9, 12, 159-160,212poverty, service population, 64,65, 118, 145, 167private hospitals, 113, 143,268,291,298

public, 190-192quality control, 167, 169, 170

regional factors, 113, 122, 148-149, 150, 170

reorganization, 161-177, 190, 192-193, 197,211-212research, 82

restrictions on public hospitals, 13, 103, 162, 212

revenues, 10, 132-133, 135, 137, 152, 162, 171, 184

specialists, associations with, 114, 143, 170, 171

staffing, general, 116, 117, 158, 167, 200State grants, 105, 131, 133

tax exempt status, 167, 183-184, 189-190, 192, 193

tax subsidies, 131, 133, 139,205-206technical assistance to, 94

transportation to, travel time, 147-149,213,412

uncompensated cam, 5, 10, 130, 131, 132, 135, 140, 157,211urban, cooperation with rural, 171-172, 173; see also Satellite

clinics

urban V. rural, 7-8,10,11,53,54,58,111, 112,113-114, 121,122,123-124,131,143, 153,158,171-172,173, 190,211,407,408,409,412-413, 420421,422

utilization, 10-11,48, 50, 51-52, 53,54, 58, 81, 83, 94, 111,112, 117-124, 145, 152, 153, 158

see also Essential Access Community Hospitals; RuralPrimary Care Hospitals; Sole Community Hospitals

Hospital Survey and Construction Act, see Hill-Burton ActHotlines, 411,426Hours of work, 229,317,318,329Hypertension, 53,76

Idaho, 337,344Illinois, 105, 174, 185-187, 191,426Immunization, 43,48,75,76

Income, business, see RevenuesIncome, personal, 6,25,38,40,42elderly, 50, 56insurance coverage and, 44,46,49, 54


patient, and travel time to physician, 243practitioner, 315,316,318-319,325-329, 331-332sliding scale fees, 75, 80underserved areas, designation criteria, 304,305urban v. rural, and Medicare, 67

see also Poverty; Wages and salariesIndian Health Service,411Indians, see Native AmericansInfant mortality, 25,26,80,288,293,298, 304,305,379,380,

387,412Infectious diseases, 80Information and information services

on alternative strategies, 211confidentiality, mental health patients, 426

83,338,340,348,350,419Public Health Act, 79Public Health Service Act, 78,335

Rural Crisis Recovery Program Act, 420

Rural Health Clinics Act, 74, 105,299,361,375

Social Security Act, 75sole/essential community hospitals, 65

Licenses and permitsallied health personnel, 281,330alternatives, 199-204,206-207,211-212clinics, 74-75,94, 105, 126-129, 167, 182, 376family practitioners, 226Federal role, 14, 16, 126-129, 192hospitals, 16,73-74, 162, 187-188, 192, 199-204M di id 16 167



databases, 26,397

long-term assessment, 17

maternal and child health grants, 75-76

mental health services, 425-426,432multiskilled practitioners, clearinghouse, 342National Library of Medicine, 347-348

public hospitals, disclosure laws, 191, 193

record technicians, 278,280,283telecommunications, 337,346-348,409State-level, 83

see also Statistical programs and activities

Institute of Medicine, 275-276,330,395-397

Insurance, see Health insurance; Malpractice insuranceIntensive care, 114, 115,409,410,411Interdisciplinary approach, 79,359

allied health personnel, multiple competencies, 21-22, 280-281,284,330,342

Iowa, 95, 105, 173,391,421

Kansas, 169

Kentucky, 38,326,360

Lab technicians, 277,279,284,330

Language issues, 80speech/language pathologists, 280

Legal issues and servicesconfidentiality, 426fraud, 13, 14-15, 184-185, 192see also Crime and criminals; Eligibility; Regulations

Legislationantitrust law, 186-188, 190-192, 193model, 15, 24public hospitals, 190-192,193State action, 95-96, 101, 103, 104, 105-106, 190-192, 193,

366,396-398Legislation, specific Federal

Anti-Drug Abuse Act, 77Clayton Act, 185Community Mental Health Centers Act, 76,418419Comprehensive Alcohol Abuse and Alcoholism Prevention,

Treatment, and Rehabilitation Act, 76Emergency Health Personnel Act and Amendments, 287,352Federal Housing Act, 138Federal Tort Claims Act, 26,397,398

Health Maintenance Organization Act, 291Hill-Burton Act, 118-120, 132, 137-138Mental Health Systems Act, 76Omnibus Budget Reconciliation Acts, 16,83,74,75,78,81,

Medicaid, 16, 167

mental health personnel, 422

midlevel practitioners, general, 319-320pharmacists, 272physicians, 308

restrictive, 13,319-320,330,375,412, 427Linking systems

discharge planning, 73,214maternal and infant care, 27

mental health services, 28,419,432434outreach, 27

referral, 16, 65, 66, 113, 162, 163, 167, 171-172, 176,

184-185, 192,205,214,339Litigation

antitrust, 184-188, 189

hospital diversification, 190

obstetric malpractice, 25 ,Loans

commercial, 138Hill-Burton Act, 119, 137-138

low-interest, 93

mortgages, 93

student aid, 22, 77-78, 92, 97, 287, 299, 301, 335, 351,

352-354,356,357,368, 431Local systems, 5

competition, 124Federal relation to, 10, 197

fundraising, 157health departments, 153, 169, 172-173,308hospitals, 113, 131, 133, 157, 175-176, 190,205-206

State assistance, 93-94, 104taxes, 15,205-206

see also terms beginning “Community.."Long-term care,

205,212hospitals, 114, 116, 143, 152Medicaid/Medicare, 70,73-74regional networks, 170

Maine, 174,366Malpractice insurance, 23,25,26,329,332,395-400, 412

midlevel practitioners, 320, 375State role, 93,97, 105,396-400,412

Manufacturing, 41,42Market forces and marketing, 94, 160, 167, 169

antitrust and, 186-188, 189, 190-192, 193physician supply, 242see also Costs

Maryland, 174

*

Index q 523

Maternal and Child Health block grant, 9,61, 62,75-76,400,404-405,411,412

Maternal and infant care, 25-27,75-76,114,163, 317,379-414Federal role, 9,25-27,61,62,75-76, 80,396,404,411,412Health Manpower Shortage Areas, 298hospital-based, 407409,410malpractice insurance, 23,93, 395400,412Medicaid, 26,400401,404,406migrant worker utilization, 53mortality, 25,26, 80, 288,293,298,304,305, 379-387,412research, 83supply/demand, 25, 145,233,390-400transportation; 93urban V. rural, 26,379-387,390,396,400, 404,407,408,409,

412

physicians and, 22-23, 24-25, 303, 326-327,331-332,348-351,367,374

primary cm, 19,20prospective payment system, 16, 61-66, 82, 132-134, 158,

164,213Rural Primary Care Hospitals and, 16,65

specialists, 67,68,325swing bed program, 73-74, 105, 163-165, 166, 177, 182, 189urban V. rural, 7,9,43,46,62-63,67-68, 131,326-327,349see also Sole Community Hospitals

Mental health services, 27-29,80,417-434community mental health centers, 28,76,418-419,420,421,

422,424425Federal role, 9,28-29,76-77,418-420, 433-434Health Manpower Shortage Areas, 286,291,294



see also Midwives

Medicaid, 9,54,61,68-75,80, 153acute and emergency treatment, 73, 211

certification requirements, 16, 167children, 43

dentists, 73diagnostic services, 70,71elderly, use of, 50eligibility, 68-70,73-75,404,406financing arrangements, general, 68,71-73,205

Health Manpower Shortage Areas, 74home services, 70

hospitals, 70-71,72,73-74,118,131, 138-139,184-185,201,212

maternal and infant cam, 26,400,401-403,404,406mental health services, 28, 71, 271midlevel practitioners, 320,321, 322,373, 375-376nurses, and Medicare, 24, 73,74, 320, 321, 322

outpatient care, 70, 71,74, 212physicians and, 22-23,24-25,63,64,65, 74,303,326-328,

400

specialists, 326State action, 68-70,74,98, 105,400swing bed program, 73-74, 105, 163-165, 166, 177, 182, 189

underserved areas, designation, 304, 305, 307,308urban V. rural, 7,9,43,46,326-327,400

Medical Economics, 329Medically Underserved Areas (MUAs), 287,291-293,294,296,

299,301,304-306,307, 309,310,311,361,362, 372Medicare, 8,9, 13, 14,50,54,61-68,80

acute and emergency treatment, 73, 211

certification requirements, 16,73-75, 167, 181-182, 199-200diagnostic services, 16,52,70,61-66

educational costs estimated, 63, 64,65, 366-367educational support, professional, 20

eligibility, 73-75, 181-182, 204financing arrangements, general, 16,61-66,82,132-134, 158,

164,202,348-350,geographic factors, 83, 146, 150Health Manpower Shortage Areas, 24-25, 67, 68, 74, 303,

320,350-351,361,367, 374hospitals, 16, 51-52, 62-66, 73-74, 118, 120-121, 130-135,

138-139,181-182,184-185, 192,199-200,201,202, 211,212

midlevel practitioners, 24, 320-322, 331, 373, 375-376nurses, and Medicaid, 24, 73, 74, 320, 321, 322outpatient care, 67, 74, 212

p g , , ,

hospital diversification, 163

hospitals, 421,422,426linkages, see Linking systems

Medicaid, 28,71substance abuse, 9,61,62,76-77,163,298, 419,422-424,426urban V. rural, 27,417,418,420-421,42244, 425,428-430,

432Mental Health Systems Act of 1980,76

Mergers, 175-176, 185-187, 192

Metropolitan areas, v. rural areas, 5-7

accidents, 43, 54allied health personnel, 281,284

community health centers, 141definition, 35,40,54dentists, 269-270,283education, 346elderly persons, 40-41, 50-52,54,55, 56health indicators, general, 43,44,45,46,54,57health insurance, 4346,48,404hospitals, 7-8,10,11,53,54,58,111, 112,113-114,121,122,

123-124,131,143,153, 158,171-172,173,190, 211,407,408,409,412413,420-421, 422

maternal and infant health, 26, 379-387,390, 396,400,404,407,408,409,412Medicaid/Medicare, 7,9,43,46,62-63,67-68, 131,326-327,

349,400mental health, 27,417,418,420421,422424, 425,428-430,

432midwives, 255

nurses, 265, 266, 267-268, 270, 282, 283, 317optometrists/ophthalmologists, 276, 277, 283pharmacists, 273-274,283physicians, 226, 229, 232, 237-238, 242-249, 282, 329,

331-332,412poverty, 40,42property tax, 190

underserved areas, designated, 287,288,294,297,301, 302,304

utilization of care, 7, 10,47-50,50-52,53,54, 58,81,82,111,112, 117-118,211

Mexico, 78Michigan, 338,418Michigan Primary Care Association model, 306,307Midlevel practitioners, 18,24,74, 168, 182, 199,203,352

education, 21,250, 319,320, 339-341, 373Medicare/Medicaid, 24, 320-322,331,373,375-376National Health Service Corps, 355,356,357,375-376


private insurance reimbursements, 320,322recruitment and retention, 319-322,373,374-375satellite clinics, 168,359, 360,367,376supply/demand, 249-268,282-283,371

see also Allied health professionals; Midwives; Nurses and

nursing; Physician assistants

Midwestern U.S.elderly, 50, 54hospitals, 111mental health, 425,426

migrant workers, 53

State role, 91,92,93,97Midwives, 18,21,24

defined, 250education, 250,320, 339-340,341,356, 358-359

deaths averted index, 309infant, 25,26,80,288,293,298, 304,305,379,380,387, 412maternal, 25, 388-389,412

suicide, 417urban v. rural, 43,44,54,417

Multidisciplinary approach, see Interdisciplinary approach

Multifacility alliances, 12, 124, 144, 161, 169-175, 177,212

National Advisory Committee on Rural Health, 16National Center for Health Statistics, 26,309National Health Interview Survey, 47,387,417

National Health Services Corps, 9,22,26,77-78,92,93, 97,351,352-358,361,362,367, 397,398

Health Manpower Service Areas, 77,296,298-299,301,303,

309,352,354-356,358, 368,375-376



malpractice insurance, 397,398,412

national association, 255, 320National Health Service Corps, 77,356,397public assistance reimbursements, 321,322

supply/demand, 249-250, 256-257, 282, 372, 397, 398,412Migrant workers

accidents, 80

Border Health Education Centers, 78

definition, 52

demography, 52-53,54-55federally funded health centers, 53, 55, 59, 80; see also

Community and Migrant Health Centers

Health Manpower Shortage Areas, 298research, 83

State role, 104

utilization of services, 53, 59Migration, from rural areas

history of, 37-38hospital viability and, 12, 146-147, 153,211,407

research, 17Mining, 41,42,80Minnesota, 81,119,145,162,170,246, 248-249,319,326-327,

336,337,422Minority groups, 6,40,54,78,79,83Black Americans, 40,380,387,388,389-390Hispanics, 53,78,83maternal and infant health, 380, 387, 388, 389-390,411

migrant workers, 53

Native Americans, 54,78,411pharmacists, 272-273professional personnel, 316

student aid, 335underserved areas, designation, 298, 304

see also Migrant workersMississippi, 38,326,397Missouri, 189,336,338Models, 211-212

basic services, 197-198,214health care networks, 15-16, 17, 168, 169,214licensing alternatives, 199-204,206-207,211-212midlevel practitioners, 24service delivery, 16State legislation, 15,24,396see also Demonstration projects

Montana, 16, 88, 200,203, 205, 206-207, 212, 337, 339, 344,348,391,426

Mortality, 5

midlevel practitioners, 355,356, 357,375-376

midwives, 77,356, 397volunteers, 77,78, 296, 299, 354, 357, 358, 368

National Institute of Mental Health, 419-420,426,430,431

National Library of Medicine, 347-348National Multiskilled Health Practitioner Clearinghouse, 342National Residency Match Program, 229

National Rural Health Association, 100-101

Native Americans, 54,78,411Nebraska, 82,274,335,419,421,428Needs assessment, Federal assistance, 9Nevada, 95,366,397,409

New Mexico, 161,336,345-346New York State, 92,95, 103-104, 146-147,316Nonprofit organizations

charitable organizations, 189

Health Manpower Shortage Areas, 289,291

hospitals, 81, 151

see also Volunteers and volunteering

North Carolina, 92,159,163,167,169,204-205, 280,319,344,366,391,397

North Dakota, 168, 170,316,425426,430-431

Northeastern U. S., 91,92,93,97,260Northern U. S., 243,371,407

Nurses and nursing, 27, 165,332anesthetists, 250, 257-259, 322, 340

defined, 250,259education, 21,79,93,250,251,257, 259,260,264,265,266,

320,323,324,339-340, 341-342,351,356,358-359, 373elderly, education of, 174employment, 24, 73, 74, 259-263, 264-268, 270, 320, 321,

322,324hospitals and, 24,73,74, 188, 189,320,321,322

hours of work, 317,318as linkage agents, 28long-term care, 116Medicaid/Medicare reimbursements, 24,73,74,320,321,322National Health Service Corps, 77private insurance reimbursements, 322recruitment and placement, 92, 93, 322-323, 341-342, 359-

360,362research, 83salaries, 326State hospital regulations, 188, 189

supply/demand, 18-19,249,250-252,257-268, 269,270,282,283,371

urban areas, 265,266,267-268,270, 282,283,317

Index q525

see also MidwivesNutritionists, see DietitiansObesity, 43

Obstetrics, see Maternal and infant careOccupational therapy, 114,277,279,283,284Office of Management and Budget, 35

Office of Maternal and Child Health, 26-27Office of Rural Health Policy (ORHP), 9,15,16,17,61,82-83,

101Offices of rural health (State-level), 90,91,96-97,98,99-100,

106

Ohio, 168Oklahoma, 92,316,344

personnel supply demand, 255,267,274,275Omnibus Budget Reconciliation Acts, 16,74,75,78,81,83,338,

340 348 350 419

335-339,432elderly, 247-248family practitioners, 226,229,230,233,245, 316,317,335,

339,397-399,412fraud regulations, restrictive, 13,14-15,184-185,192general practitioners, 226, 229, 233, 245, 268, 270, 317,

393-394,395,397general practitioners, 226, 229, 233, 245, 268, 270, 317

393-394,395,397geographic distribution, 238,242,242,243,337hospital licensing requirements, 203hospitals, financial associations with, 166-167,176-177,185,

187-188, 192,319hours of work, 317,329,331income, 318-319, 325-329Medicaid 22 23 67 68 71 72 73 74 205 304 308



340,348,350,419Optometrists, 19,274-275,276,277,283Oregon, 157,293,360,366Osteopathic medicine

educational costs, 323-324Health Manpower Shortage Areas, 289

supply/demand, 220, 225-226, 231-232, 234-238, 239, 247,282

Outmigration, see Migration

Outpatient services, 81, 120, 122-123, 152, 162, 165-167, 176,

201,202,212ambulatory surgery, 13,67,80, 114, 122-123, 134-136, 162,

163,212Medicaid, 70,71,74,212Medicare, 67,74,212

Outreach, maternal and infant care, 27

Ownership of enterprise

hospitals, 111, 113, 138, 185

property tax, 189-190, 193

Paraprofessionals, mental health, 27,29,431Parasitic diseases, 53,80Patient education, 62, 174,432

Pennsylvania, 163, 189,246Pesticides, 53

Pharmacology and pharmacists, 80

education, costs, 324

prescriptions, 168-169,320,430supply/demand, 19, 272-274, 283

Physical therapists, 277,278,279,283,284Physician assistants, 18, 19,23, 168-169

defined, 250education, 250,253, 319,320, 339,340

Medicaid reimbursements, 74Medicare reimbursements, 24,74

recruitment and placement, 92, 93, 362State regulation of, 319-320supply/demand, 249, 252-255, 256, 282, 372

Physician bonus payment program, 24-25, 303, 350-351, 361,

367,374Physician Payment Review Coremission, 325, 326, 348, 350Physicians

allopathic medicine, 220,225,232,249,318, 323-324anesthesiologists, 258

basic services, 199community health centers, 80

education, 63,64, 65,220, 225,226,249, 316-317,323, 324,

Medicaid, 22-23, 67-68, 71, 72, 73, 74, 205, 304, 308,

326-328,400Medicare, 22-23, 24-25, 63, 64, 65, 74, 303, 326-327,348-350,367,374

as mental health providers, 27,430,432,433National Health Service Corps, 77,351,352,352-359,398opinions, diagnoses, 52, 71, 318osteopathic medicine, 220, 225-226, 231-232, 23-238, 239,

247,282,323-324recruitment and retention, 77,92,93,94, 145, 167, 170, 183,

185,242,243,315-319, 335-339,351,352-359, 362specialists, supply, 226, 227-228, 229, 230, 231, 233, 242,

324,331student loan repayment aid, 22, 77-78, 287, 299, 301, 351,

352-354,356,357,368supply/demand, 5,8, 17-18,20, 116,219-249,315-316, 318,

319,324,371underserved areas, criteria, 288-289,293,296, 298,309urban V. rural, 226, 229, 232, 237-238, 242-249, 282, 329,

331-332,412utilization, 47, 50, 51, 54, 58, 127see also Malpractice insurance

Pl anning

community health centers, 159-160discharge, 73,214

Federal role, 16-17,214hospitals, 9, 12, 159-160,212State, 104-105

Pests and pesticides, 76

Policy issuesFederal role, 9, 15, 16, 17,61,82-83State role, 91

Population factors, see Demography

Poverty, 6-7,38,40,42,44,54,80, 105county-level classification, 41essential services criteria, 14, 204, 213health care networks, 15hospitals, serving poor, 64,65, 118, 145, 167

maternal and child health grants, 75, 404Medicare, 213migrant workers, 53

physicians, travel time to, 243State actions, 205student aid, 335

undersexed areas, designation criteria, 289, 291, 293, 298,305,307

women, 389-390


see also MedicaidPregnancy, see Maternal and infant carePreventive care, 47,54,80

immunization, 43,47,75,76screening, 43,70,75, 80, 167,411,432see also Patient education

Preventive Health and Health Services block grant, 9,61,62,76Primary care, 5,79-81, 168-169,174

closure, 145-146education, 79hospital-based, 167Medicare payments, 19,20mental health, 420,430,432physician supply, 18,27,226,229,230,232, 245-246,247,

282,315-316,318,331, 371,430,432State action 90 91 98 105

income and practice costs, 315, 316, 319, 325-329, 331-332maternal and infant care, 23,25,93, 145, 233,39040mental health care, 27-29,426-427optometrists, 19,274-275,276,277, 283statistics, 24-25supply/demand, 5, 8, 17-19, 20, 25, 116, 145, 219-284,

287-311,318,319,371-376, 39040,426431turf guarding, 212,375,433see also Allied health personnel; Bureau of Health Profession-

als; Employment and unemployment; Health Manpower

Shortage Areas; Licenses and permits; Medically Under-

served Areas; Midlevel practitioners; National HealthServices Corps; Nurses and nursing; Physician assistants;

Physicians; Recruitment and retention; Volunteers and

volunteering

Projections



State action, 90,91,98, 105

tax incentives, 23underserved areas, designated, 288-289,293, 294,297, 298,301,302,303,304,306, 307

see also Area Health Education Centers; Community healthcenters; Rural Primary Care Hospitals

Primary Care Cooperative Agreements, 9, 16,90Prisons, 289,291Private hospitals, 113, 143,268,291,298Professional education

allied health professions, 21-22,275,280-281283, 284,330,342,373

Area Health Education Centers, 21-22, 78, 100, 299, 301,343-346,361,362,367, 373,374

Association of American Medical Colleges, 226Border Health Education Centers, 78career choice and, 315-317, 318costs, 63,64, 64, 323-325,331, 338, 374,423dentists, 423Federal assistance, 9, 20-22, 24, 28, 78-79, 301, 316, 335,

338-348,367,372,373-374foreign graduates, 229,231,247,248funding, general, 9,20-21,335,339-340, 352-358Medicare cost estimates and, 63,64,65,366-367Medicare support for, 20mental health, 28,431-432,433midlevel personnel, 21,250,319,320, 339-341,373midwives, 250, 320, 339-340,341, 358-359nursing, 250,251,257,259,260, 264,265,266,320,323, 324,

339-340,341-342,351, 358-359,373optometrists, 274pharmacists, 272,273physician assistants, 250,253,319,320,339, 340

physicians, 63,64,65,220,225,226, 249,316-317,323,324,335-339,432recruitment and retention strategies, 335-346, 366, 373-374specialization, 315-316,317,324,326State role, 23,24,95,97, 105, 188,301,306telecommunications, 337,346-348,373-374see also Student aid

Professional personnel, 17-25associations of, 100-101,216, 226,229, 230,251, 255, 274,

275,319,320,329,398, 399,412clergy, 430-431

family practitioners, 226,229,230,233,245, 316,317,335,339,341,393-394,395, 396,397-399,412

hospital staff, 116, 117, 158, 167,200

Projections

nurse supply, 260, 264optometrist supply, 274pharmacist supply, 273

physician education, enrollments, 225physician supply, 220-225,230,231,248-249

Prospective payment system, 16,61-66,82, 132-134,158,164,213

Psychologists, 27,28,426-427Public assistance

Aid to Families with Dependent Children, 68-69,70

health care centers, 8, 140-141

hospitals, 130-131maternal and infant care, 25-26,321-322,410

see also Eligibility; Medicaid; MedicarePublications

State, 91,93,96Public education, 21-22,80

for children of practitioner, 318elderly, 174

Public Health Act, 79

Public Health Foundation, 76

Public Health Service, 26,77,205,352,355,358, 398Public Health Service Act, 78,335

Public relations, 160, 161, 162

Quality control, 5,122,212hospitals, 167, 169, 170needs assessment, 9

Peer Review Organizations, 121see also Licenses and permits; Regulations; Standards

Racial differences, 38,40

maternal and infant care, 380, 387,388,389-390see also Minority groups

Radiologists, 277-278,280,283,284, 330RAND Corp., 242,244-245Rape, 76

Record technicians, 278,280,283Recruitment and retention, health care personnel, 8,9,22,23,81,

145,167,170,183,185, 242,243,282,315 -332,359-368,372-376,426,428

educational strategies, 335-359leave, 93,348

telecommunications, 337,346-348, 373-374State role, 91,92-93,94,96,97,98

Referral, 16,65,66, 113, 162, 163, 167, 171-172, 176,

Index *527

184-185, 192,205,214,339Regional trends

age distribution, 42,50,54,55,56community health centers, 140economic factors, 41,42funding, 90

Health Manpower Shortage Areas, 297,371hospitals, 113, 122, 148-149, 170maternal and infant care, 27,393 -395,396,399,409-410, 411migrant workers, 53networks, 16,204, 207,214,330nurse supply, 260, 261-262, 264physician assistant supply, 253physician supply, 220,224-225,229,234-238, 239-241population characteristics, 41State-related, 90,91

i b d 166

351,352,353,356,357, 367,368,374Screening, 43,70,75,80,167Seatbelts, 43,54Self-help groups, 431Sex differences, 6,231

see also Women

Smoking, 43Social Security Act, 75Social services and social workers, 27-28,82

counseling services, 424,427Medicaid, 73self-help groups, 431

Sole Community Hospitals (SCHs), 13, 14, 65, 66, 117-118,133, 149-150, 153,213,270

South Carolina, 344,397South Dakota, 92-93, 168,347,421S h U S



swing bed programs, 166

underserved areas, 300utilization, 127see also Appalachia; Central U. S.; Eastern U. S.; Midwestern

U. S.; Northeastern U.S.; Southern U. S.; SouthwesternU. S.; Western U.S.

Regulations, 197

Federal, 181-188, 199-200,211,212fraud, 13, 14-15, 184-185, 192

State, 15,103,162,188-192,211, 212,319-320,330,375,412see also Eligibility

Renal disease, 64,65Research

access to cam, 17, 144-145demography, 83

Federal aid for, 9, 17,61,82-83,420market, 94

mental health, 420perinatal care, 26

on regulatory impacts, 15State role, 91,94,95student debt, 324-325

see also Demonstration projectsRespiratory therapists, 278,279,280

Revenuescommunity health centers, 140-141, 142, 153

hospitals, 10, 132-133, 135, 137, 152, 162, 171, 184tax exempt, 67, 183-184, 189-190, 192, 193

Robert Woods Johnson Foundation, 345,411Rural Health Care Transition Grant, 9, 16,81,214Rural Health Caucus, 5

Rural health clinics (RHCs), 13,74, 126-127certification, 74-75, 94, 105, 126-129, 167, 182, 376

mental health services, 27midlevel practitioners, 320, 322

Rural Health Clinics Act, 74, 105,299,361,375Rural Health Research Center, 82

Rural Infant Care Program, 411

Rural Mental Health Demonstrations, 420,433Rural Primary Care Hospitals (RPCHs), 16,65,204,207,212,

214

Safety, see Accidents and accident prevention

Salaries, see Wages and salariesSatellite clinics, 168,359,360,367,376Scholarships, 22,23,77,78-79,92,97, 298,301,316,323,335,

Southern U.S.

economics, 41,42,54elderly, 50, 54hospitals, 150nurse supply, 260physician supply, 233,238,242,371State role, 91,92,93,97underserved areas, 299, 303

Southwestern U.S., 53,242Specialists and specialized services, 211,220,226,227-228

allied health personnel, 275,277-282

anesthetists and anesthesiologists, 250, 257-259,332,340audiologists, 280choice of, 315, 316, 331dental, 268,271dietitians, 279-280education, general, 315-316,317,324,326family practitioners, 226,229,230,233,245, 316,317,335,

339,341,393-394,395, 396,397-399,412Health Manpower Shortage Areas, 298hospitals, 114, 143, 170, 171Medicaid payments, 326

Medicare payments, 67,68,325optometrists, 19, 274-275, 276, 277, 283physician assistants, 254,255,256physicians, supply, 226, 227-228, 229,230, 231,233, 242,

324,331radiologists, 277-278undersexed areas, designation, 304utilization, 47, 51see also Maternal and infant care; Midwives; Physician

assistants; SurgerySpeech pathologists, 280Spouses, 317-318,331Standards, 13

community health centers, 13, 183essential services, 13-15,66, 198, 204, 213Federal role, 17, 119, 192, 199-200supply statistics, 219, 220State role, 91student aid/loan repayment, 352, 354, 356,431underserved areas, criteria, 287,288-293,296,299, 298,301,

303-311,362,372see also Eligibility

State-level action, 87-106, 197-205acute and emergency treatment, 91, 105, 198, 201,202, 203


administration, 24,68,89-91,96-97,98, 99-101,104, 106capital investment financing, 103, 104definition, 87,89definition of rural area, variations in, 38

education, 23, 24, 95, 97, 105, 188, 301, 366Federal relation to, 10, 14,15,23-24,75,87,89-90, 93,101,

106,301,302,303-308, 311,361,362,368funding, 23-24,89-91,93,100, 105-106,130-131,133, 363,365,428,433

hospital subsidies, 101, 131, 133

legislation, 95-96,101,103,104,105-106, 190-192,193,366,396-398

local areas, assistance to, 93-94, 104malpractice, 93,97, 105, 396-400,412maternal and infant care, 396-400,412Medicaid, 68-70,74,98, 105,400mental health services 421 425 426 433

fetal and infant health indices,380-387, 390, 391; see also Infant mortality

mental health, 29

metropolitan statistical areas, 35, 36

perinatal care, 26

population, 35-60

professional personnel, 24-25professional practice cost index, 329professional supply data, standards, 219,220State collection efforts, 24-25

underserved area indices, 309

see also Demography; Epidemiology; State-level statistical

dataStatutes, see Legislation; Legislation, specific Federal

Student aid, 366

loans, 22,77-79, 92,97,287, 299,301, 335,351, 352-354,356 357 368 431



mental health services, 421, 425-426, 433

midlevel practitioners, 319-322nurse supply, 260

offices of rural health, 90,91, 96-97,98, 99-100, 106personnel grants, 23-24personnel supply/demand, 246,246-249,251,255, 267,274,

275,391physician supply studies, 246-247

primary care, 90, 91,98, 105recruitment and retention, 91,92-93,94,96,97,361-366, 368,

375

regulations, 15, 103, 162, 188-193, 211, 212, 319-320, 330,375,412

statistics collection, 25

student loan repayments, 22,78,92,97, 301, 351,352,354,356-357,368,431

technical assistance, 15,91,93-94,98, 105,205,212underserved areas, 301, 302, 303-308, 311, 372

see also Licenses and permits; specific StatesState-level statistical data (tables)

ambulatory surgery, 136

anesthetists, 258

community health centers, 125coordination, 96

education, 97, 363general, survey of, 88-89,91,98-102issues, rankings, 102Health Manpower Shortage Areas, 297

Medicaid, 72,98,321Medicare, 136,321

maternal and infant health indices, 381-387, 393-395migrant workers, 60nurses, 258, 261-263

optometrists/ophthalmologists supply, 276physician assistants, 253physicians, 220,222-225,227-228, 234-238,239-241population, 39,40recruitment and placement, 91,92-93, 94,96, 97, 363, 364research, 95

rural health clinics, 128specialists, 227-228

swing bed programs, 166technical assistance, 94

underserved areas, 308

Statistical programs and activitiesdefinitional issues, 35,37,38,40-41,53-54

356-357,368,431

mental health education, 29scholarships, 22, 23, 77, 78-79, 92, 97, 298, 301, 316, 323,

335,351,352,353,356, 357,367,368,374tuition reimbursement, 92-93

Substance abuse, 9,61,62,76-77,163,298, 419, 422-424, 426Suicide, 417,420Supplemental Security Income, 68,75

Supplementary Medical Insurance, 61

Surgery, 10, 114, 122

ambulatory, 13,67,80,114,122-123, 134-135,162,163,212maternal and infant, 410

Medicaid, 71,326Medicare, 326

State regulation, 188

Swing bed program, 73-74,105,163-165,166, 177, 182,189

Task forces, 16-17,96, 104, 105

Taxes

exemptions, 167, 183-184, 189-190, 192, 193hospital subsidies, 131, 133, 139,205-206

incentives, primary caregivers, 23

local, 15,205-206property, 189-190, 193

Technical assistanceFederal, 9, 10, 14,25,26,27,212maternal and infant care, 26, 27

State, 15,91,93-94,98, 105,205,212statistics collection, 25

Technology, 120, 121, 123, 170acute care, 114allied health personnel, 280-281ultrasound, 409

Telecommunications, 337,346-348,373-374, 409Telephone services, 411,426Tennessee, 93, 105-106, 189Texas, 93,95, 105, 157, 160, 189,344-345,346,366, 397

personnel supply/demand, 251,255,267,274,391Torts, 26,396,397,398

see also Malpractice insuranceToxic substances, 53,76

children, lead-based paint, 75Transportation, 17,80

hospitals, travel time to, 147-149,213,412mental health patients, 426,432

physicians, travel time to, 238,242,243

Index q 529

public, 6State funding, 93travel time to services, general, 309

Uncompensated care, 5, 10, 130, 131, 132, 135, 140, 157,211,329,332

Underserved areas, 61, 126, 150,287-311see also Health Manpower Shortage Areas; Medically

Underserved AreasUninsured patients, 5,6-7,50,54,82,105,211, 213,305,331,

390,400,401403Urban areas, see Metropolitan areas

Urban Institute, 309Utah, 169, 171, 174, 189, 198-199,251,255,257, 337Utilization, 47-50,211

community health centers, 127, 152-153

deficit index, 309elderly, 51-52,58

charitable organizations, 189

mental health care, 29,431National Health Service Corps, 77, 78, 296,299, 354, 357,

358,368

Wages and salaries

allied health personnel, 281-282Medicare, wage index, 62-63

National Health Service Corps, 355-356,357

mental health workers, 28

nurses, 326

physicians, 318-319,325-329, 331, 355-356

Washington State, 147, 159, 197-198,206,337,344, 391,397,408,428

Western U.S., 41,91,92,93,97, 149, 150,316professional personnel supply/demand, 238,242,243,260,

d d 303



hospital, 10-11,48,50,51-52,53, 54,58,81,83,94,111,112,117-124, 145,152, 153, 158mental health services, 420-426,432

midlevel practitioners, 359migrant workers, 53, 59physicians, 47,50,51,54,58, 127urban v. rural, 7,10,47-50,50-52,53, 54,58,81,82,111,112,

117-118,211

Vacation, 93,348Vermont, 157, 189,422

Virginia, 174, 185-187,344,397,422Volunteers and volunteering

underserved areas, 303

West Virginia, 71, 160, 174

Wisconsin, 131-132, 168, 170

Women, 163

allied health professionals, 275

mortality, 25,388-389

pharmacists, 272physicians, 229

poor, 389-390

rape, 76

see also Maternal and infant care; Sex differences

Wyoming, 71,73,203

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